Intussusception is a medical condition, in which a proximal part of the intestine folds into the distal intestine. Adult intussusceptions are rare and account for approximately 5% of all cases of intussusceptions. The anatomical leading points include tumors, diverticulums, polyps, and strictures in 80-90% of adult intussusceptions, and 65% of colon intussusceptions and 30% of small bowel intussusceptions originate from malignant tumors. Treatments for adult intussusception have not been established, but most cases require surgical treatment. The gastrointestinal tract is the most common extranodal site for non-Hodgkin lymphoma. The symptoms are mostly non-specific, but they rarely lead to complications, such as bleeding, perforation, and intussusception. Furthermore, few cases of primary gastrointestinal lymphomas causing intussusception have been reported. This paper reports a case of small bowel diffuse large B cell lymphoma that caused ileocolic intussusception in a 69-year-old woman with no medical history. She underwent a small bowel resection and received six cycles of adjuvant chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. Since then, she has been in complete remission.

Neutropenic enterocolitis is a fatal enterocolitis occurring in neutropenic patients with immunocompromised diseases including hematologic malignancies. Gastrointestinal (GI) mucormycosis in hematologic malignancies has been rarely reported. Especially, in myelodysplastic syndrome (MDS), GI mucormycosis has never been reported. We report a case of GI mucormocysis manifesting as neutropenic enterocolitis in a patient with MDS.

BACKGROUND:Rectal neuroendocrine tumors (NETs) < 10 mm in diameter, limited to the submucosa without local or distant metastasis, can be treated endoscopically. Endoscopic mucosal resection with a ligation band device (EMR-L) and endoscopic submucosal dissection (ESD) have been employed to resect rectal NETs. We evaluated and compared the clinical outcomes of EMR-L and ESD for endoscopic resection of rectal NETs G1 < 10 mm in diameter.METHODS:We conducted a retrospective study of 82 rectal NETs in 82 patients who underwent either EMR-L or ESD. Therapeutic outcomes (en bloc resection and complete resection rates), procedure time, and procedure-related adverse events were evaluated. Additionally, we measured the distance of the lateral and vertical margins from the border of the tumor in pathologic specimens and compared the resectability between EMR-L and ESD.RESULTS:Sixty-six lesions were treated using EMR-L and 16 using ESD. En bloc resection was achieved in all patients. The complete resection rate with EMR-L was significantly higher than that with ESD (95.5% vs.75.0%, p = 0.025). The prevalence of vertical margin involvement was significantly higher in the ESD group than in the EMR-L group (12.5% vs. 0%, p = 0.036), and ESD was more time consuming than EMR-L (24.21 ± 12.18 vs. 7.05 ± 4.53 min, p < 0.001). The lateral and vertical margins were more distant in the EMR-L group than in the ESD group (lateral margin distance, 1661 ± 849 vs. 1514 ± 948 μm; vertical margin distance, 277 ± 308 vs. 202 ± 171 μm).CONCLUSIONS:EMR-L is more favorable for small rectal NETs with respect to therapeutic outcomes, procedure time, and technical difficulties. Additionally, EMR-L enables achievement of sufficient vertical margin distances.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 136 hanced abdominal CT showed neither remarkable abnormal findings in the GI tract nor significant lymphadenopathy. We decided to perform endoscopic submucosal dissection (ESD) for accurate diagnosis, and en bloc resection was achieved successfully (Fig. B, yellow arrow: SET). Written informed consent was obtained. Based on above information, what is the most likely diagnosis? pISSN 1598-9100 • eISSN 2288-1956 https://doi.org/10.5217/ir.2019.00112 Intest Res 2020;18(1):136-138

Duodenal neuroendocrine tumors (NETs) are rare, and risk factors associated with lymph node (LN) metastasis are still not well defined. The aim of this study was to investigate risk factors of LN metastasis in duodenal NETs based on the final histopathologic results and clinical follow-up data. This study included a total of 44 duodenal NETs in 38 patients who underwent endoscopic or surgical resection between January 2008 and December 2015. Diagnosis of duodenal NETs was confirmed based on immunohistochemical staining of chromogranin A, synaptophysin, and CD56; the clinicopathologic records were collected at the time of the initial diagnosis of duodenal NETs. Most duodenal NETs were small (<= 1 cm in 33 tumors), World Health Organization (WHO) grade G1 (in 32 tumors), limited to the mucosa and/or submucosa (in 40 tumors), and located at the duodenal bulb (in 32 tumors). Of 44 tumors, lymphovascular invasion was present in 4 (9.1%), and among 38 patients, LN metastasis was detected in 4 (10.5%). LN metastases were significantly associated with the non-bulb location, tumor size >10 mm, tumor invasion into the muscularis propria or deeper, WHO grade G2, and lymphovascular invasion. During the mean follow-up period of 54.5 months (range, 24-123 months), recurrence occurred in 1 patient. Non-bulb location, tumor size >10 mm, invasion beyond the submucosa, WHO grade G2, and lymphovascular invasion are risk factors of LN metastasis in duodenal NETs. These findings can help clinicians choose the appropriate therapeutic modality for duodenal NETs.

Question: A 60-year-old man with C3 tetraplegia was referred to our department for evaluation of abdominal pain and hematochezia. He was diagnosed with adrenal insufficiency 5 years prior and has been taking low-dose prednisolone (7.5 mg) once a day. One year before presentation, he complained of intermittent loose, mucoid stool and abdominal pain. Sigmoidoscopy revealed multiple small yellowish plaques in the sigmoid colon (Figure A). However, symptoms improved without any treatment, and he was discharged from the rehabilitation department.

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant hereditary disorder caused by germline mutation of the MEN1 gene. It is characterized by tumors of the anterior pituitary gland, parathyroid glands, and endocrine pancreas. Thymic carcinoid tumor is uncommon and associated with a high mortality, but its natural history has not been investigated yet. We report a case of asymptomatic MEN 1 with a thymic carcinoid tumor. A 37-year-old man underwent a routine medical checkup and upper gastrointestinal endoscopy revealed a duodenal neuroendocrine tumor (NET). Further studies showed the coexistence of pancreatic tumor, parathyroid hyperplasia, pituitary adenoma, and thymoma. The patient underwent duodenal endoscopic mucosal resection, distal pancreatectomy, subtotal parathyroidectomy, and thymectomy. The pathological test revealed a duodenal NET, pancreatic NET, parathyroid hyperplasia, and thymic carcinoid tumor. He was treated for MEN 1. We report this asymptomatic case of MEN 1 with a literature review.

Needle-knife fistulotomy (NKF) commonly used to overcome difficult bile duct cannulation as a rescue methods. Safety and efficacy of NKF as primary procedure was not confirmed. Especially, the difference of the complication rate according to the experience of endoscopist was not well known. So, there are limited data on primary NKF for the access to bile duct in patients with naïve papilla. We aimed to assess the difference of safety and complications according to endoscopist's experience. We performed a retrospective study, in 613 patients who had naïve papilla and no history of pancreatitis and underwent bile duct cannulation by two endoscopist at a tertiary referral center. Patients were classified by three group according to utilization of cannulation: 127 patients underwent conventional cannulation (group 1), 84 patients failed conventional cannulation and then, underwent P-duct stent insertion and/or precut fistulotomy (group 2), and 90 patients underwent primary fistulotomy (group 3).[DUK] We evaluated the ERCP-related complications between modified two method group and additionally between expert and beginner. [DUK vs DHB, N=301 vs 312] Between two endoscopist groups, there were no significant differences in baseline characteristics. The post-ERCP pancreatitis (PEP) rate was not significantly different between three method groups (10.2%:6.2%:2.2%, p=0.072) in experienced endoscopist. But cannulation time and procedure time were significantly different between three groups (3.9min:11.7min:5.0min , p=0.000). There are no clinically significant difference bleeding or perforation in three groups. If we had devide patients by primary NKF vs non-primary NKF, there are significantly different between in PEP (2.2%:8.5%, p=0.042), and hyperamylasemia (5.5%:15.0%, p=0.026). And when we performed analysis to different between expert and beginner. There was significantly difference in PEP on non-primary NKF group (8.7%:15.3%, p=0.024). However, there was no significantly difference in PEP on primary NKF (2.2%, 4.9%, p=0.332). And other complications were not significantly difference. Primary NKF is effective and safe in achieving ductal access in patients with naïve papilla. And the complication rates of primary NKF was less influenced by endoscopist's experience than conventional cannulation.Tabled 1compared result between three method group in experienced endoscopistTotalGroup 1 (N=127)Group 2 (N=84)Group 3 (N=90)P valueSuccess rate295 (98 %)127 (100%)80 (95.2%)88 (97.8 %)0.180Cannulation time (min)6.4 ± 6.93.9 ± 4.811.7 ± 7.75.0 ± 5.70.000*Total Procedure time (min)18.0 ± 10.915.7 ± 8.223.9 ± 12.715.7 ± 10.30.000*Post-ERCP pancreatitis20 (6.7 %)13 (10.2%)5 (6.2%)2 (2.2%)0.072Hyperamylasemia39 (13.2 %)19 (14.9%)12 (15.0%)5 (5.5%)0.083Bleeding6 (2.0%)2 (1.5%)1 (1.3%)2 (2.2%)0.868* significantly different in statistics : p value < 0.05 Open table in a new tab Tabled 1compared result between two endoscopists.Endo group 1Endo group 2P valueGroup 1/2 (Total N)211247Success rate98.1 %95.5%0.101Cannulation time (min)7.1 ± 7.26.5 ± 7.10.340Total Procedure time (min)19.2 ± 10.817.5 ± 9.50.080Post-ERCP pancreatitis18 (8.7%)36 (15.3 %)0.024*Hyperamylasemia31 (15.0%)44 (18.6 %)0.184Bleeding3 (1.4%)7 (3.0 %)0.228Group 3 (Total N)9065Success rate97.8 %93.8 %0.203Cannulation time (min)5.0 ± 5.75.6 ± 4.40.494Total Procedure time (min)15.7 ± 10.314.1 ± 7.50.310Post-ERCP pancreatitis2 (2.2%)3 (4.9 %)0.332Hyperamylasemia5 (5.5%)5 (8.1 %)0.388Bleeding2 (2.2%)4 (6.5 %)0.188* significantly different in statistics : p value < 0.05 Open table in a new tab

Subepithelial lesions(SEL) of the colon are discovered by accident. Clinically, most of them are not induced symptoms. However, there is required for the caution because of malignancy potential. Some studies have addressed the role of endoscopic ultrasonography(EUS). However, there are currently rare clinical data for SEL, therefore, we aimed to assess the character of each lesions and to analyze the clinical outcomes of SEL. We performed a retrospective observational study of 428 consecutive patients(462 lesions) who underwent colonoscopy for SEL between January 2010 to December 2016 at the Pusan National University Hospital. The EUS findings and results of long-term follow up for each lesion were analyzed. Of 462 lesions, 207(44.8%) lesions were on the right-sided colon (including cecum, ileocecal valve, ascending colon and transverse colon), 49(10.6%) lesions were on the left-sided colon (including descending and sigmoid colon), 202(43.7%) lesions were on rectum, and 4(0.9%) lesions were through whole colon. The most common lesion was carcinoid tumor (133/462, 28.8%) and most of them were located in rectum. EUS was carried out in 200 lesions(43.3%), and therapeutic managements (including EMR, ESD, full biopsy and surgery) were performed in 170 lesions. Comparing the observation group and the treatment group about the long term clinical results, 4 (1.4%) lesions of the observation group were progressed, while no progressions were seen in the treatment group. Subepithelial lesions of colon are detected below 1% of total colonoscopic inspection and may be no more evaluation if the lesions are found to typical findings with small size. However, when they are discovered as atypical findings or larger size(≥ 1cm), it is need to effort to diagnose precisely using histological or image modality because of potential malignancy.Tabled 1Table 1. Clinical and Endosonographic characteristicsN= 462 lesionsMean size mm (range)LocationEUS findingsRightLeftCecumWholeLayerEchogenicityActinomycosis (n= 1)100.013, 4hypoCarcinoid tumor (n= 133)6.4 (2-40)1332, 3hypoEndometriosis (n=4)20.5 (15-35)224hypoExternal compression (n= 20)21.3 (3-40)965hypoFibroepithelial polyp (n= 3)12.7 (3-30)33hypoFibroma (n= 2)10.0 (3-17)112 - 4mixedGIST (n= 8)33.1 (4-70)352 or 4hypoGranular cell tumor (n= 5)2.0 (2-10)412, 3hypoHemangioma (n= 3)28.7 (8-43)21IFP (n= 3)4.7 (3-8)212, 3hypoInflammation (n= 60)8.3 (2-50)2516192, 3hypoLeiomyoma (n= 8)23.9 (5-3)1162 or 4hypoLipoma (n= 139)12.3 (5-50)1181563HyperLymphangioma (n= 41)25.3 (7-40)3473AnLymphoma (n= 6)21.2 (5-32)123MALToma (n= 5)17.8 (3-35)412, 3hypoMetastatic lesion (n= 2)27.5 (20-35)11Mucinous neoplasm (n= 4)23.0 (7-30)133 - 4hypoOther vessel (n= 1)3.023hypoPhleboectasia (n= 1)3.01Pneumatosis coli (n= 3)35.0 (20-50)113AnRectal abscess (n= 3)9.3 (8-20)33hypoRectal tonsil (n= 4)6.8 (3-10)42, 3hypoRectal varix (n= 1)8.013hypoSchwannoma (n= 2)8.0 (7-9)23, 4hypo Open table in a new tab Tabled 1Table 2. Comparison the treatment group and the observation group about the long term clinical outcomesTreatment groupObservation groupNF/U duration, months, mean (range)No. of progressionsNF/U duration, months, mean (range)No. of progressionsActinomycosis143.Carcinoid tumor13223.2 (1-75).118.Endometriosis11.37.7 (1-19).External compression2018.1 (1-49).Fibroepithelial polyp136.231.0 (8-54).Fibroma221.0 (18-24).GIST358.7 (51-70).523.2 (2-51)1Granular cell tumor47.0 (2-19).122.Hemangioma315.7 (24-43).IFP319.3 (9-38).Inflammation722.7 (4-52).5327.2 (1-64).Leiomyoma246.0 (30-62).622.3 (3-48).Lipoma533.8 (13-71).13416.5 (1-75).Lymphangioma525.2 (11-41).3627.1 (2-57).Lymphoma621.8 (5-48)1MALToma141.424.5 (21-54).Metastatic lesion210.0 (6-14)2Mucinous neoplasm437.3 (28-44)Other vessel126.Phleboectasia138.Pneumatosis coli332.7 (20-54).Rectal abscess31.3 (1-3).Rectal tonsil410.3 (2-15).Rectal varix110.Schwannoma113126. Open table in a new tab

Heterotopic pancreas is a common subepithelial lesion in the stomach, but its histological diagnosis is usually difficult when tissue samples are obtained with a conventional biopsy forceps. The aim of this study was to describe the magnifying endoscopy with narrow-band imaging (ME-NBI) features of gastric heterotopic pancreas. We retrospectively analyzed a database of all patients who underwent endoscopic ultrasonography (EUS) at Pusan National University Hospital from January 2010 to December 2010. A total of 36 patients with endosonographically diagnosed as heterotopic pancreas who underwent ME-NBI at the same time were included in the study. ME-NBI features of their lesions were analyzed. Thirty lesions were located in the antrum, and 6 lesions were located in the body. Six lesions (17%) showed an umbilication or central dimpling on the surface, and 9 lesions (25%) had a macroscopic opening on the surface. On ME-NBI, a microscopic opening was identified in 22 (81%) of 27 lesions in which a macroscopic opening was not observed during conventional endoscopy. As a total, a macroscopic or microscopic opening was observed in 31 lesions (86%). The frequency of a macroscopic or microscopic opening was higher in lesions with anechoic duct-like structures than in lesions without anechoic duct-like structures on EUS (91% [29/32] vs 50% [2/4], P = 0.027). Focal loss of microsurface structure and presence of a thickened submucosal vessel were observed in 6 lesions (17%) and in 5 lesions (14%), respectively. The characteristic ME-NBI feature of heterotopic pancreas is presence of a microscopic opening on its surface. This ME-NBI feature is potentially useful for differentiating heterotopic pancreas from other subepithelial tumors in the stomach.Tabled 1Magnifying endoscopy with narrow-band imaging of gastric heterotopic pancreasMicroscopic opening, n (%)Present31 (86)Absent5 (14)Focal loss of microsurface structure, n (%)Present6 (17)Absent30 (83)Thickened submucosal vessel, n (%)Present5 (14)Absent31 (86) Open table in a new tab

Crohn's disease (CD) is a chronic relapsing inflammatory disease and its prevalence is high in both Western and Asian countries. Patients with CD experience frequent hospitalization, so unexpected socioeconomic costs are occurred. We aimed to assess the clinical characteristics and risk for CD-related hospital admissions. We reviewed retrospectively medical records of patients who were diagnosed with CD between January 2013 and December 2016 in a single tertiary hospital. We compared the group of admitted patients and the group of outpatient. We included demographic characteristics (age, sex) and clinical characteristics (symptoms, disease extent, use of drugs, laboratory findings at diagnosis). A total of 87 patients were diagnosed with CD at Pusan National University Hospital. Among them, 34 (39.1%) patients had history of hospitalization. For overall 87 CD patients, mean age was 30.0 years old (range: 14–72), 60 (69.0%) patients were male sex, and mean follow up period were 26 months (range: 2-58). In the initial clinical practice, steroid use (p= 0.044), high level of C-reactive protein (CRP, p=0.007), white blood cell (WBC, p=0.006) counts and low level of albumin (p=0.049) were associated with hospital admission compared with the control group. In contrast, there were no association was found to age, sex, smoking history, perianal operation history and presence of stricture and fistula. CD-related hospitalization was related with a steroid use, high level of CRP, WBC and low level of albumin at diagnosis. Therefore, these patients are required to early step up treatment strategy and close follow up.Tabled 1Table 1. Clinical and Baseline CharacteristicsNAge, yr (range)30 (14-72)Male sex, n (%)60 (69.0)Follow-up duration, months (range)26 (2-58)SymptomsAbdominal pain, n (%)67 (77.0)Diarrhea, n (%)40 (46.0)Weight loss, n (%)23 (26.4)Anal pain, n (%)20 (23.0)Hematochezia, n (%)19 (21.8)Fever, n (%)8 (9.2)Arthritis, n (%)7 (8.0)Nausea/Vomiting, n (%)7 (8.0)Melena, n (%)3 (3.4)Others, n (%)2 (2.3)Drugs5-ASA, n (%)70 (80.5)Steroid, n (%)33 (37.9)Antibiotics, n (%)20 (23.0)AZA/MTX, n (%)8 (9.2)PPI, n (%)7 (8.0)Disease statusPerianal disease, n (%)49 (56.3)Stricture, n (%)30 (34.5)Abdominal abscess, n (%)7 (8.0)Fistula, n (%)3 (3.4)Extraintestinal manifestation, n (%)2 (2.3)Montreal classificationA1, n (%)3 (3.4)A2, n (%)52 (59.8)A3, n (%)13 (14.9)L1, n (%)11 (12.6)L2, n (%)15 (17.2)L3, n (%)41 (47.1)L4, n (%)1 (1.1)B1, n (%)40 (46.0)B2, n (%)23 (26.4)B3, n (%)5 (5.7)Perianal, n (%)25 (28.7) Open table in a new tab Tabled 1Table 2. Comparison between the outpatient group and the inpatient groupOutpatient group(N= 53)Inpatient group(N= 34)p-valueAge, yr (range)29.9 (14-64)29.1 (17-72)0.985Male sex, n (%)40 (75.8)20 (58.8%)0.101Smoking Hx, n (%)8 (15.1)8 (23.5)0.322Active smoking, n (%)5 (9.4)3 (8.8)1.000Family Hx, n (%)3 (5.7)1 (2.9)1.000Perianal op Hx, n (%)20 (37.7)11 (32.4)0.609Appendectomy, n (%)2 (3.8)1 (2.9)1.000Bowel resection, n (%)3 (5.7)00.277Drug5-ASA40 (75.5)25 (73.5)0.258Steroid18 (34.0)15 (44.1)0.044AZA/MTX3 (5.7)5 (14.7)0.107Antibiotics14 (26.4)6 (17.6)0.748Laboratory findingsC-ANCA (+)00P-ANCA (+)00ASCA IgG (+)15 (28.3)11 (32.4)0.881ASCA IgA (+)3 (5.7)1 (2.9)0.638WBC, /uL7889 (3700-13540)9425 (4070-16860)0.006Hemoglobin, g/dL (range)13.4 (8.4-18.6)12.5 (8.3-17.8)0.081Platelet, x10/uL (range)352.6 (56-639)376.8 (218-624)0.308ESR, mm/hr (range)19.9 (2-73)29.3 (2-103)0.116CRP, mg/dL (range)1.52 (0.02-6.67)4.35 (0-27.19)0.007Albumin, g/dL (range)4.1 (2.9-4.9)3.8 (2.5-5.3)0.049Montreal classificationA1, n (%)2 (3.8)1(2.9)1.000A2, n (%)43 (81.1)28(82.4)0.886A3, n (%)8 (15.1)5(14.7)0.960L1, n (%)5 (9.4)6 (17.6)0.327L2, n (%)9 (17.0)6 (17.6)0.936L3, n (%)38 (71.7)22 (64.7)0.492L4, n (%)1 (1.9)01.000B1, n (%)35 (66.0)24 (70.6)0.658B2, n (%)17 (32.1)6 (17.6)0.136B3, n (%)1 (1.9)4 (11.8)0.074Perianal, n (%)14 (26.4)11 (32.4)0.550 Open table in a new tab

We presented a case of unusual endobronchial inflammatory polyps as a complication following endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in a patient with tuberculous lymphadenitis. EBUS-TBNA of the right hilar lymph node was performed in a 29-year-old, previously healthy man. The patient was confirmed with tuberculous lymphadenitis and received antituberculosis medication over the course of 6 months. Chest computed tomography, after 6 months of antituberculosis therapy following the EBUS-TBNA showed nodular bronchial wall thickening of the right main bronchus. Histological and microbiological examinations revealed inflammatory polyps. After 7 months, the inflammatory polyps regressed almost completely without need for removal.