A 31-year-old patient with no previous history of inflammatory bowel disease (IBD) underwent further evaluation for recurrent episodes of intestinal obstruction. Abdominal computed tomography revealed thickening of the wall of the ascending colon and dilated small-bowel loops ([Fig. 1]). Colonoscopy disclosed a large polypoid mass with fingerlike projections in the right colon ([Fig. 2]). Progression of the endoscope beyond this point was not possible. Biopsies were negative for malignancy. Prompted by the suspicious endoscopic appearance of the lesion and the signs of intestinal obstruction, a right-sided hemicolectomy was carried out. The resected specimen included a mass with multiple clustered polyps with several branches that almost completely obliterated the lumen of the colon ([Fig. 3]). Microscopic examination was consistent with giant filiform polyposis ([Fig. 4]). The nonpolypoid mucosa of the terminal ileum and right colon was normal.

A 53-year-old patient was admitted to the gastroenterology department for the management of a benign biliary stricture secondary to chronic alcoholic pancreatitis. He underwent sphincterotomy and placement of a 10Fr×10cm plastic biliary stent. Endoscopic follow-up 2 months later revealed spontaneous migration of the stent and no further intervention was performed. The patient was admitted to the general surgery outpatient clinic 7 years later for the management of a recurrent pilonidal abscess. Excision of the abscess revealed a long fistulous track towards the coccyx with a plastic stent inside it (●" Fig.1a,b); the findings indicated a rectocutaneous fistula secondary to biliary stent migration. In addition, computed tomography scan showed a 1-cm defect of the sacrococcygeal junction in contact with the rectum (●" Fig.2). Postoperatively, the patient was treated with antibiotics and vacuum-assisted closure therapy and went on to make an excellent recovery. His follow-up over 4 years was unremarkable. Complications of stent placement are well known and include migration with fistula formation between a variety of organs, such as: duodenocolic fistula [1], duodenoscrotal fistula [2], enterosplenic fistula [3], enterocutaneous fistula [4], and colovaginal fistula [5]. However, to the best of our knowledge recurrent abscess secondary to a rectocutaneous fistula has not been described previously.

A 53-year-old woman was admitted with upper abdominal discomfort. Clinical examination revealed a mass of the upper left quadrant. Computed tomography disclosed a giant cystic lesion of 19 x 16 cm compressing the body and tail of the pancreas as well as the left kidney. Endoscopic ultrasound showed an anechoic lesion with multiple septa. Diagnostic fine needle aspiration was performed. Intracystic carcinoembryonic antigen and lipase values were normal. However, carbohydrate antigen 19-9 level was elevated (3433 UI/ml) and cytologic examination was compatible with a pancreatic serous cystadenoma. Prompted by the symptoms and the lack of a definite diagnosis, the patient underwent cystectomy. Surprisingly the histological diagnosis was that of a benign renal cyst. To date, only one case of a giant renal cyst has been reported with high levels of CA 19-9. With this case report we would like to demonstrate that giant renal cysts may present high levels of CA 19-9 and mimic the endoscopic ultrasound aspect and cytologic features of pancreatic cysts.

A 77-year-old man was admitted for evaluation of recurrent episodes of cholangitis. He had undergone endoscopic retrograde cholangiography (ERC) several times for biliary stone disease and for cholecystectomy, and suffered from advanced Alzheimer disease. Abdominal magnetic resonance imaging (MRI) revealed dilatation of the right posterior intrahepatic duct, with aberrant drainage directly into the common hepatic duct. However, multiple attempts to reach this segment by ERC were unsuccessful. The Spyglass system was then used for selective opacification and optical viewing of the aberrant bile duct (Boston Scientific, Natick, Massachusetts, USA).A reddish nodular lesion was seen obstructing the lumen, and targeted biopsies with a 3-Fr Spybite mini-forceps (Boston Scientific) confirmed the presence of an adenoma. The stricture was dilated with a Hurricane 8-mm, 4-cm balloon (Boston Scientific) and the stones were extracted. The Spyscope was removed and two 7-Fr plastic stents placed. Given the patient’s poor mental and general status, we proposed carrying out endobiliary radiofrequency ablation of the stricture. This was done 4 weeks later with a wire-guided Habib EndoHPB (Emcision, London, UK). This case illustrates the potential impact of selective cholangioscopy with the Spyglass system on diagnosis and management of indeterminate biliary strictures.

BACKGROUND:The current procedures for percutaneous endoscopic gastrojejunostomy (PEG-J) tube placement require fluoroscopy and are time consuming. We describe a new, simple method.METHODS:Ten patients had a PEG-J tube placed by the new method. After placement of a percutaneous endoscopic gastrostomy (PEG) tube using standard technique, the PEG tube was pushed up to the pylorus to make it easier to place the jejunal tube into the duodenum without looping in the stomach. Fluoroscopy was not used. The position of the tube was confirmed by a plain x-ray film of the abdomen.RESULTS:The mean time required for PEG placement and jejunal tube placement was 9.0 and 8.2 minutes, respectively. In all patients the tip of the jejunal tube was at the ligament of Treitz. In one patient the jejunal tube formed a loop in the duodenum, but this was reduced by spontaneous forward migration. In another patient, the tube migrated back into the stomach after 1 week.CONCLUSION:The method described allows easier PEG-J placement without fluoroscopy.

Endoscopic treatment of superficial gastric cancer has been reported to be effective by many Japanese teams. In this study, the Nd:YAG laser was used to treat superficial gastric carcinoma in inoperable Caucasian patients with the aim of obtaining a complete response, i.e., disappearance of the lesion endoscopically and biopsy specimens negative for cancer. Eighteen patients unsuitable for surgery with various endoscopic patterns of superficial gastric cancer were treated with the Nd:YAG laser. The endoscopic pattern was type I in 4 patients, type II in 10 (5 type IIa, 1 type IIb, 2 type IIc, 2 mixed IIa + IIc), and type III in 4. Staging by echoendoscopy was performed in 11 patients (T1N0). Nd:YAG laser destruction of the gastric tumor was performed in all cases, with a mean of 4.4 laser sessions per patient. Tumor response was assessed by endoscopy and biopsy. Follow-up averaged 33 +/- 23 (SD) months. Five patients died of diseases unrelated to gastric cancer. An initial complete response was obtained in 16 (89%) patients after a mean of 1.7 laser sessions; histologic evidence of cancer persisted in 2 patients during the entire follow-up period. Among patients with an initial complete response, recurrence was observed in 2. One of them was successfully re-treated. At the end of the follow-up period, 14 (77.7%) of the 18 patients had a complete tumoral response; only 4 patients had histologic evidence of cancer. In 3 of these 4 patients, pretherapeutic echoendoscopic staging had not been performed. Among the 14 patients exhibiting a complete response, 3 had negative biopsy results more than 5 years after diagnosis. No complications occurred. In gastric cancer classified as T1N0 on the basis of pretherapeutic echoendoscopy, a high tumor response rate and even 5-year disease-free survival can be obtained with endoscopic Nd:YAG laser treatment. Endoscopic laser destruction thus appears to be a valuable therapeutic alternative to surgery in inoperable patients with superficial gastric cancer.

We report the results of endoscopic photocoagulation in the treatment of villous adenomas of the rectum in 49 consecutive patients (26 males, and 23 females, mean age: 74 years). Twenty-six patients were treated with a high-power Nd-Yag laser (80 W/sec). After a mean of 3.4 laser sessions, all the small-sized adenomas (C1) and 88% of the intermediate-sized adenomas (C2) were healed. No extensive villous adenoma (C3) could be eradicated. Complications occurred in 5 patients. Recurrence was observed in 3 C2 patients who are still on maintenance laser therapy. Twenty-three patients were treated with another Nd-Yag laser (maximal power output: 45 W/sec). After a mean of 6.4 laser sessions, 85% of the C1 patients were healed, while eradication of villous tissues was obtained in 60% of C2 and C3 patients. No complications were noted. A recurrence was observed in three C1 patients with secondary healing after reinstitution of laser therapy in 2 cases. Moreover, two C3 patients also relapsed and laser eradication was again obtained in 1 patient. In conclusion, these results confirm the efficacy of laser therapy in small- and intermediate-sized villous adenomas of the rectum. The number of laser sessions required for eradicating a villous tumour was lower using a high-power Nd: Yag laser, but the risk of complications was increased.

Using ambulatory 24 hour pH monitoring, intragastric acidity was measured in 6 healthy volunteers and 8 patients with duodenal ulcer. According to a latin square design each patient was randomly assigned to receive placebo, 300 mg ranitidine at 19.00 h or 300 mg ranitidine at 22.00 h, on three separate occasions. Validation of the method was achieved by comparing the values indicated by the intragastric electrode and the pH of simultaneously aspirated gastric juice (y = 0.87x + 0.66, r = 0.93). Comparing the area under the curve of intragastric hydrogen ion activity, as well as the percent of time less than pH 5, we found a better inhibition of nocturnal acidity (20.00 h-08.00 h) with 19.00 h ranitidine than with ranitidine administered at 22.00 h (p less than 0.01). By contrast, there was no significant difference in diurnal acidity between both ranitidine regimens and placebo.

UNLABELLED:Many methods are used to treat villous adenomas of the rectum. The best choice between these methods is not well established. Ninety-six patients (47 men, 49 women) treated with endoscopic monopolar coagulation were studied. The mean age was 66 years (range 37-84). The lesions were located in the lower third of the rectum in 27 cases, in the middle third in 35 cases and in the upper third in 34 cases. The circumferential extent of the lesions was less than 1/3 in 70 cases (C1), greater than 1/3-less than 2/3 in 23 (C2) and greater than 2/3 in 3 cases (C3). The follow-up of 2 patients (1 C1 and 1 C2) was not sufficient. Healing was not achieved in 8 of the 94 evaluated patients. Eighty-six patients were totally healed: 68 C1, 16 C2 and 2 C3 with a follow-up of 2 to 132 months (median: 36 months). The treatment was achieved after a mean of 2.1 sessions per patient (range 1-13).CONCLUSIONS:1) Endoscopic monopolar coagulation of villous adenoma of the rectum is a simple and efficient treatment. 2) This method is complementary to surgery for extensive lesions (C3).

The presence of Campylobacter pylori in duodenal ulcer was investigated in 26 patients. The method used was a sterile endoscopic sampling technique which forcasted and checked for contamination of the samples. A sterile catheter was introduced through the endoscope and then an infusion of saline was instituted. Once the catheter was in the intestinal lumen, the infused solution was aspirated for control of sterility. Semi-quantitative cultures of gastric and duodenal juices and of biopsies of the duodenal ulcer, the bulbar mucosa close to the ulcer and prepyloric antral mucosa were compared. Only two contaminations were detected with this method. C. pylori was isolated in one gastric and one duodenal sample only. It was isolated in 14 of 26 duodenal ulcers, 12 of 26 bulbar mucosa and 20 of 26 mucosal specimens. Our study established that the presence of C. pylori was very uncommon in gastric and duodenal juices even when the bacterium was present in the mucosal membrane in large quantities.

The presence of Campylobacter pylori in duodenal ulcer was investigated in 26 patients. The method used was a sterile endoscopic sampling technique which forcasted and checked for contamination of the samples. A sterile catheter was introduced through the endoscope and then an infusion of saline was instituted. Once the catheter was in the intestinal lumen, the infused solution was aspirated for control of sterility. Semi-quantitative cultures of gastric and duodenal juices and of biopsies of the duodenal ulcer, the bulbar mucosa close to the ulcer and prepyloric antral mucosa were compared. Only two contaminations were detected with this method. C. pylori was isolated in one gastric and one duodenal sample only. It was isolated in 14 of 26 duodenal ulcers, 12 of 26 bulbar mucosa and 20 of 26 mucosal specimens. Our study established that the presence of C. pylori was very uncommon in gastric and duodenal juices even when the bacterium was present in the mucosal membrane in large quantities.