BACKGROUND:Conflicting reports exist on the correlation of fecal calprotectin (FC), with the endoscopic severity of small bowel lesions of Crohn's disease (CD). This study aimed to analyze the correlation between FC and small bowel lesions observed by small bowel capsule endoscopy (CE). METHODS:This prospective multicenter study involved patients aged 16 to < 60 years with CD of ileal or ileocolonic types without a history of intestinal resection. The participants underwent CE, ileocolonoscopy, and FC within a period of 1 month. Patients with active colonic lesions were excluded. Endoscopic remission (ER) was defined as the absence of an ulcer (≥ 5 mm). The primary endpoint was to determine whether FC could be used to define ER of small bowel lesions in patients with CD. The secondary endpoints were the correlation of CE activity and FC. RESULTS:The study involved 49 patients. The correlation between FC and Lewis score was positive with r = 0.436 (P = .002). The receiver operating characteristic curve constructed for ER and FC had an area under the curve of 0.828 (95% confidence interval, 0.694-0.962; P < .001). The cutoff FC for ER was calculated to be 175 μg/g. The correlation between FC and Capsule Endoscopy Crohn's Disease Activity Index was positive with r = 0.542 (P < .001). CONCLUSIONS:This study revealed a correlation between small bowel CE activity and FC. Under this condition, small bowel ER can be defined as an FC level of < 175 μg/g, and FC was suggested to be a useful biomarker for monitoring small bowel lesions during the application of treat-to-target strategies.

BACKGROUND:Fecal calprotectin has been proposed as a useful biomarker of disease activity in inflammatory bowel disease (IBD). However, the role of calprotectin in systemic circulation is not well established. Thus, this study aimed to quantify serum calprotectin levels to identify a potential inflammatory marker for IBD.METHODS:Ninety-eight patients with ulcerative colitis (UC) and 105 patients with Crohn's disease (CD) were prospectively enrolled and clinically scored. Ninety-two healthy, age-matched subjects served as controls. Blood samples from UC and CD patients and controls were analyzed for serum calprotectin levels and routine laboratory parameters. Disease activity was assessed by partial Mayo score and Harvey-Bradshaw index for UC and CD, respectively.RESULTS:Serum calprotectin levels were higher in CD and UC patients than in controls and were higher during active disease than during inactive disease in CD but not in UC. In UC, serum calprotectin levels were correlated with C-reactive protein (CRP) but not with other laboratory parameters or disease activity. In CD, serum calprotectin levels were positively correlated with disease activity, serum CRP, and platelet count. In UC and CD, serum calprotectin and CRP levels increased during the acute phase and decreased towards remission.CONCLUSIONS:Serum calprotectin is an inflammatory marker in IBD but might be more effective in evaluating patients with CD than those with UC. Further studies are needed to confirm these findings and to better determine the specific uses of serum calprotectin in routine practice.

Studies on serum leucine-rich alpha-2 glycoprotein (LRG) in inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD), are scarce; the methods for estimating disease activity are less established, particularly for CD. This study is aimed at evaluating the utility of serum LRG as a potential inflammatory marker for IBD and to investigate the LRG gene expression in peripheral blood mononuclear cells (PBMCs) as a possible source of serum LRG. Overall, 98 patients with UC and 96 patients with CD were prospectively enrolled and clinically evaluated; 92 age-matched individuals served as the healthy controls. The blood samples were analyzed for serum LRG levels and routine laboratory parameters. Disease activity was assessed clinically and endoscopically. Finally, LRG gene expression in the PBMCs from a different cohort (41 patients with UC, 34 patients with CD, and 30 healthy controls) was examined. The serum LRG levels were higher during active disease than during inactive disease; additionally, serum LRG levels were positively correlated with clinical disease activity, C-reactive protein (CRP) levels, and other laboratory parameters in patients with UC and CD and with endoscopic disease activity in UC. UC and CD showed comparable areas under the curve (AUC) values for determining clinical remission and differentiating between endoscopic remission associated with LRG and CRP. The levels of LRG mRNA were also increased in PBMCs from patients with UC and CD and reflected disease activity. These data suggest that serum LRG, originated partially from PBMCs, is an inflammatory marker in UC and CD. A large-scale well-designed study should be conducted in the future to more accurately reveal the clinical significance of LRG in patients with IBD.

Objective Real-world data of adalimumab (ADA) in the treatment of ulcerative colitis (UC) are scarce. We aimed to study the ADA response rates and predictors of response in UC treatment. Methods This observational, prospective and multi-center study assessed the clinical outcome of refractory UC patients treated with ADA who previously had an inadequate response to either conventional therapies or other anti-TNF antibodies or tacrolimus. The primary endpoint was the proportion of UC patients achieving a clinical response and remission at 8 and 52 weeks. We also evaluated the parameters which were associated with a clinical response at 8 and 52 weeks. Results A total of 35 patients were enrolled from 11 centers. The clinical responses at 8 and 52 weeks were 60.0% and 51.4%, respectively. The clinical remission rates at 8 and 52 weeks were 45.7% and 48.6%, respectively. Positive predictors for week 52 response were combination of ADA with immunomodulator (IM) (OR: 27.229; 95% CI; 1.897-390.76; p=0.015) and a week 8 lower partial Mayo score (OR: 0.406; 95% CI; 0.204-0.809; p=0.010). A receiver operation characteristic curve analysis revealed the optimal week 8 partial Mayo score to be 2.5, therefore a partial Mayo score of ≤2 was a positive predictor for the continuation of ADA. No malignancy or death occurred during this study. Conclusion ADA was effective for inducing and maintaining both a clinical response and remission in patients with refractory UC. It remains possible that the concomitant use of IM and a week 8 partial Mayo score of ≤2 may predict the long-term response of ADA.

Supplemental Digital Content is available in the text Abstract This study aimed to investigate the short-term effectiveness of adalimumab therapy in patients with ulcerative colitis (UC), especially its rapid response. This retrospective, multicenter, cohort study involved 7 institutes in Japan, compiling data from patients with UC who had received at least 1 induction dose of 160 mg of adalimumab between June 2013 and May 2017. Patients should have a Lichtiger clinical activity index score of ≥5 at the initial adalimumab administration. Remission was defined as clinical activity index score of ≤4, whereas response was defined as a reduction of ≥50% from the baseline value. Rapid responders are defined as patients who achieved response at 2 weeks. A total of 91 patients were included in this study: 37.4% and 45.1% achieved clinical response at 2 and 8 weeks, respectively, whereas clinical remission rates 12 weeks were 45.1%. Among the rapid responders, 82.4% achieved clinical remission at 12 weeks. Multivariate logistic regression analysis identified a higher platelet count as an independent prognostic factor for a higher rate of rapid response. Receiver operating characteristic curve showed that a platelet counts cutoff value of ≥312 × 109/L was associated with a rapid response. Approximately 40% of patients with UC showed a rapid response to adalimumab therapy after 2 weeks. Up to 80% of the rapid responders also achieved remission at 12 weeks. A higher platelet count was identified as an independent prognostic factor for a higher rapid response rate.

Small bowel stricture is one of the most common complications in patients with Crohn’s disease (CD). Endoscopic balloon dilatation (EBD) is a minimally invasive treatment intended to avoid surgery; however, whether EBD prevents subsequent surgery remains unclear. We aimed to reveal the factors contributing to surgery in patients with small bowel stricture and the factors associated with subsequent surgery after initial EBD. Data were retrospectively collected from surgically untreated CD patients who developed symptomatic small bowel stricture after 2008 when the use of balloon-assisted enteroscopy and maintenance therapy with anti-tumor necrosis factor (TNF) became available. A total of 305 cases from 32 tertiary referral centers were enrolled. Cumulative surgery-free survival was 74.0% at 1 year, 54.4% at 5 years, and 44.3% at 10 years. The factors associated with avoiding surgery were non-stricturing, non-penetrating disease at onset, mild severity of symptoms, successful EBD, stricture length < 2 cm, and immunomodulator or anti-TNF added after onset of obstructive symptoms. In 95 cases with successful initial EBD, longer EBD interval was associated with lower risk of surgery. Receiver operating characteristic analysis revealed that an EBD interval of ≤ 446 days predicted subsequent surgery, and the proportion of smokers was significantly high in patients who required frequent dilatation. In CD patients with symptomatic small bowel stricture, addition of immunomodulator or anti-TNF and smoking cessation may improve the outcome of symptomatic small bowel stricture, by avoiding frequent EBD and subsequent surgery after initial EBD.

Background and Aim: Interleukin-22 (IL-22), plays a vital role in the mucosal repair of inflammatory bowel disease (IBD). Serum levels of IL-22 and IL-22 binding protein (IL-22BP), a soluble inhibitory IL-22 receptor, were measured in patients with IBD to investigate the profile of IL-22 in the systemic circulation. Methods: Blood samples from 92 healthy subjects, 98 patients with ulcerative colitis (UC), and 105 patients with Crohn's disease (CD) were analyzed for serum levels of IL-22, IL-22BP, human beta-defensin 2 (hBD-2), and serum inflammatory parameters. Disease activity was assessed by the partial Mayo score and Harvey-Bradshaw index for UC and CD, respectively. Results: Serum IL-22 level was lower in UC (P< 0.001) and CD (P< 0.001) vs control and its decrease was more pronounced in CD than in UC (P = 0.019). Serum IL-22BP level was lower in UC (P< 0.001) and CD (P< 0.001) vs control and correlated with inflammatory parameters (albumin and C-reactive protein (CRP) in UC; hemoglobin, albumin, and CRP in CD). Serum IL-22/IL-22BP ratios were higher in UC (P = 0.009) vs control and correlated with inflammatory parameters (albumin and CRP). Serum hBD-2 level was higher only in CD (P = 0.015) but did not correlate with serum IL-22 levels, IL-22BP levels, IL-22/IL-22BP ratios, or inflammatory parameters. Conclusions: Dysregulation of the IL-22 system in the blood may play a role in the pathogenesis of IBD. Further studies are needed to understand the pathogenic and clinical significance of the blood IL-22 system in IBD.

This case report presents two males with drug-induced liver injury acquired from working at a glass factory dealing with silica and 2,2-dichloro-1,1,1-trifluoroethane (HCFC-123). Within one month of work, both patients presented with fever, icterus with liver dysfunction, and eosinophilia. Case 1 had experienced recurrence of symptoms twice while working and showed positive results for the drug-induced lymphocyte stimulation test (DLST). Meanwhile, case 2 was diagnosed by liver biopsy and clinical course but was negative for DLST. Hazard of exposure to non-crystalline silica is low, but drug-induced liver injury after exposure to HCFC-123 has been reported. Allergic liver injury is also caused by chemical substances;however, the insight into whether this injury is caused by exposure to silica or HCFC-123 remains unclear. Further studies are required to examine the influence of silica and HCFC-123 on drug-induced liver injury among glass-factory employees.

Background: Pneumocystis jirovecii pneumonia (PJP) is highly fatal once infection is established. In this study, we investigated the risk of PJP mortality in patients with inflammatory bowel disease (IBD). Methods: We conducted a retrospective observational study of case data from IBD patients who developed PJP, compiled from 17 collaborating institutions. Parameters such as age, sex, medications used, and blood test results were analyzed to identify risk factors for mortality. Results: The mortality rate among the 28 IBD patients who developed PJP was 17.9%. A low serum albumin level at the start of IBD treatment was identified as a risk factor for mortality and showed the following association with probability of death (P): P = 1/[1 + exp(–5.5 + 2.4 × Alb). The probability of death exceeded 0.5 when serum albumin was 2.2 g/dL or lower. Conclusion: Patients with IBD who develop PJP have a high mortality rate and often cannot continue treatment with medication alone. Therefore, it is necessary to pay attention to albumin levels at the start of immunosuppressive therapy when creating a treatment plan.

Background/Aims The influences of Helicobacter pylori eradication therapy on the disease course of inflammatory bowel disease (IBD) are still unclear. We therefore conducted a multicenter, retrospective cohort study to evaluate the safety of H. pylori eradication therapy for IBD patients. Methods IBD patients with H. pylori eradication from 2005 to 2015 (eradication group) and control patients (non-eradication group; 2 paired IBD patients without H. pylori eradication matched with each eradicated patient) were included. IBD exacerbation (increased/additional IBD drug or IBD-associated hospitalization/surgery) and disease improvement based on the physicians’ global assessment were investigated at baseline, and at 2 and 6 months after eradication or observation. Results A total of 429 IBD (378 ulcerative colitis, 51 Crohn’s disease) patients, comprising 144 patients in the eradication group and 285 patients in the non-eradication group, were enrolled at 25 institutions. IBD exacerbation was comparable between groups (eradication group: 8.3% at 2 months [odds ratio, 1.76; 95% confidence interval, 0.78–3.92; P=0.170], 11.8% at 6 months [odds ratio, 1.60; 95% confidence interval, 0.81–3.11; P=0.172]). Based on the physicians’ global assessment at 2 months, none of the patients in the eradication group improved, whereas 3.2% of the patients in the non-eradication group improved (P=0.019). Multivariate analysis revealed that active disease at baseline, but not H. pylori eradication, was an independent factor for IBD exacerbation during 2 months’ observation period. The overall eradication rate was 84.0%–comparable to previous reports in non-IBD patients. Conclusions H. pylori eradication therapy does not alter the short-term disease activity of IBD.

Background: There are few studies on the short-term efficacy of adalimumab treatment for patients with Crohn's disease (CD). Here, we report the results of the Short-term Outcomes of Adalimumab for Patients with Crohn's disease and Associated Prognostic Factors: A Multicentre Retrospective Cohort Study in Japan (SAPPORO). Methods: The SAPPORO study was conducted at 9 institutions. Data were retrospectively collected from CD patients who received adalimumab from October 2010 to September 2015. Patients had to have a Harvey–Bradshaw index (HBI) of ≥5 points at the first adalimumab administration. The HBI score and C-reactive protein (CRP) level were investigated at baseline and at 2, 4, 8 and 12 weeks following adalimumab administration. Remission was defined as an HBI score of ≤4. Rate of remission and remission with a normal CRP level were assessed at 2, 4, 8 and 12 weeks. The prognostic factors associated with the rate of remission with a normal CRP level at 4 and 12 weeks were evaluated using univariate and multivariate logistic regression analysis. Results: Of the 160 patients included in this study (median age, 29.3 years), 56 were female. The HBI scores significantly decreased sequentially from baseline to 2, 4, 8 and 12 weeks as follows: 8.0, 4.0, 3.3, 3.4 and 3.5, respectively. The CRP levels also significantly decreased sequentially as follows: 2.43, 0.71, 0.95, 0.91 and 1.37 mg/dL, respectively. Rates of remission at 2, 4, 8 and 12 weeks were 61%, 73%, 71% and 69%, respectively, while rates of remission with a normal CRP level were 36%, 51%, 49% and 49%, respectively. In the univariate analyses, previous infliximab (IFX) use, penetrating disease, a disease duration of ≥4.3 years, previous bowel resection, being ≥29.3 years old and CRP levels of ≥1.55 mg/dL were significant prognostic factors for a lower rate of remission with a normal CRP level at 4 and 12 weeks. In addition, a body mass index (BMI) of ≥18.5 and HBI of ≥7 were significant prognostic factors for a lower remission rate with a normal CRP level at 12 weeks. In the multivariate logistic regression analysis, previous IFX use and CRP levels of ≥1.55 mg/dL were identified as independent predictors of a lower rate of remission with a normal CRP level at 4 and 12 weeks. Furthermore, a BMI of ≥18.5 was identified as an independent predictor for a lower rate of remission with a normal CRP level at 12 weeks. Conclusions: The short-term efficacy of adalimumab treatment for CD patients was demonstrated by the second week. Approximately 50% of the patients achieved remission with a normal CRP level at 4 weeks. Previous IFX use, higher CRP levels and a higher BMI appear to be associated with poor short-term outcomes of adalimumab treatment.

A 27-year-old woman with Crohn's disease, who had sustained clinical remission for two years following treatment with mesalazine and nutrition therapy, was admitted to our hospital complaining of dry cough, mild dysphagia, and slight fever. A computed tomography of the chest demonstrated an increase in the thickness of the tracheal wall. Bronchoscopy showed a diffusely erythematous and edematous mucosa with whitish granular lesions in the trachea and main carina. Bronchial biopsy specimens showed epithelioid cell granuloma. We diagnosed tracheobronchitis as an extraintestinal manifestation of Crohn's disease. She was treated with 40mg/day prednisolone. Her symptoms improved immediately. However, dry cough recurred two months after prednisolone treatment, and further treatment with inhaled steroids was prescribed. Tracheobronchial involvement in Crohn's disease is rare, with only 13 cases having been reported. Tracheal involvement should be considered in Crohn's disease patients with respiratory symptoms.

Background: In Japan, tacrolimus is used to treat patients diagnosed with refractory ulcerative colitis (UC); however, there are few studies on the efficacy of tacrolimus treatment. The aim of this study was to analyze the short- and long-term outcomes of tacrolimus treatment in patients with refractory UC and to identify the prognostic factors associated with treatment outcomes. Methods: Data were retrospectively collected from 52 patients diagnosed with refractory UC who were treated with tacrolimus at our hospital from 2009 to 2014. Patients had to have a Lichtiger clinical activity index (CAI) of ≥5 points at baseline. Response was defined as a CAI reduction of ≥4, and remission was defined as a CAI of ⩽4. CAI was calculated at baseline and 2 and 12 weeks following tacrolimus administration. The cumulative non-colectomy rate and the sustained remission rate among patients who achieved remission after 12 weeks were estimated using the Kaplan–Meier method. Univariate analysis was used to identify the prognostic factors of remission at 2 and 12 weeks, the cumulative non-colectomy rate, and the sustained remission rates. Results: Of the 52 patients (mean age, 38.5 yr), 17 were female. The mean duration of disease was 5.1 years. At baseline, the mean CAI and C-reactive protein (CRP) levels were 9.9 and 1.46 mg/dL. Thirty-four patients had pancolitis and 18 had left-sided colitis. In terms of steroid response, 28, 22, and 2 patients were classified as steroid-resistant, steroid-dependent, and steroid-intolerant, respectively. Concomitant treatment with 5-aminosalicylic acid, azathioprine or 6-mercaptopurine, and prednisolone was administered to 43, 28, and 24 patients, respectively. Twenty-five patients had previously undergone cytapheresis, and 30 patients had previously received infliximab. Two weeks after tacrolimus treatment, CAI and CRP levels significantly decreased from 9.9 to 6.1 and from 1.46 to 0.43 mg/dL, respectively. After 2 weeks, the response and remission rates were 54% and 37%, respectively, and after 12 weeks they were 40% and 37%, respectively. Younger age was significantly associated with a higher remission rate at 2 weeks, whereas previous infliximab treatment was significantly associated with lower remission rate at 12 weeks. The 1-, 3-, and 5-years cumulative non-colectomy rates were 59%, 57%, and 53%, respectively, and the 1-, 3-, and 5-years sustained remission rates were 73%, 43%, and 35%, respectively. Concomitant treatment with azathioprine or 6-mercaptopurine was significantly associated with higher rates of sustained remission. Previous treatment with infliximab and pancolitis significantly increased the risk of colectomy. Conclusions: Approximately 40% of the Japanese UC patients treated with tacrolimus achieved remission after 12 weeks. However, 60% of these patients experienced a flare-up, and 50% of all patients required a colectomy within 5 years. Previous treatment with infliximab and pancolitis UC were significantly associated with poor outcomes following tacrolimus treatment, whereas concomitant treatment with azathioprine or 6-mercaptopurine was associated with favorable outcomes.

A 19-year-old male with diarrhea, abdominal pain, fever, and elevated C-reactive protein (CRP) levels was admitted to our hospital. Endoscopic examination and small intestinal contrast radiography revealed multiple longitudinal ulcers in the large intestine and ileum. A specimen biopsied from one of these ulcers revealed non-caseating epithelioid cell granuloma. He also had a draining anal fistula. Plain chest computed tomography (CT) and abdominal contrast-enhanced CT did not reveal any vascular abnormality. A diagnosis of Crohn's disease was made, and infliximab was administered. Following infliximab administration, the diarrhea and abdominal pain disappeared, longitudinal ulcers in the large intestine healed (as evidenced by endoscopic examination), and his anal lesion improved. However, fever and elevated CRP levels persisted. With the concomitant use of prednisolone, the fever and elevation of CRP levels eventually improved, and the patient was discharged. Both, however, recurred as the patient was weaned off prednisolone treatment; consequently, he was re-hospitalized. Contrast-enhanced CT upon re-admission revealed stenoses of the right renal artery, left common carotid artery, and left subclavian artery. In addition to Crohn's disease, the patient was diagnosed with co-existing Takayasu's arteritis.

Methods:This was an open-label, uncontrolled, multicentre trial conducted in the United Kingdom, France, and Germany, including 95 patients (18-75 years) with steroid-dependent active UC (clinical activity index [CAI] ≥ 6; endoscopic activity index [EAI] ≥ 4, and insufficient response or intolerance to immunosuppressants (IS) and/or tumour necrosis factor (TNF) inhibitors.Patients received at least 5 and up to 10 GMA aphereses in a single induction series over up to 10 weeks.Primary endpoint was the remission rate (CAI ≤ 4) at week 12. Secondary efficacy endpoints included clinical response (reduction in CAI of ≥ 3), steroid-free remission, and colectomy rates.Patients were followed-up until week 48.Results: In the ITT population (N = 95), remission and response rates were 37.2% and 53.2%, respectively, at week 12.At weeks 24 and 48, remission rates were 34% and 33%, respectively; response rates were 44.7% and 39.4%, respectively.For 30 patients who failed IS and anti-TNF, 30%, 33.3% and 20% were in remission at weeks 12, 24, and 48, respectively.Steroid-free remission at weeks 12, 24, and 48 was achieved by 19.2%, 19.2%, and 18.1%, respectively.Sustained remission or response was observed in 27.7% of patients at 48 weeks.IS medication was kept stable during the trial; steroids were significantly reduced.Quality of life (QoL) improved throughout the trial.Further 13 out of 94 (13.8%) patients had a colectomy by week 48.No patient died.No life-threatening opportunistic infection occurred.In addition, 80 patients (84.2%) experienced mild-to-moderate AEs (majority UC-related or headache); 22 subjects experienced SAEs, but none related to treatment; 26 patients (27.4%) discontinued the study because of AEs (UC-related, 21.1%; and poor vascular access, 13.7%).Conclusions: We describe a cohort of steroid-dependent moderate-tosevere active UC patients with failure or intolerance to previous treatment with IS and/or anti-TNF, treated with GMA apheresis induction therapy.Clinical benefit was seen in over 50%, 44.7%, and 39.4% of patients at weeks 12, 24, and 48, respectively.Colectomy rates up to 48 weeks (13.8%) in these non-preselected patients were comparable to published results for anti-TNF treatment at 1 year. 1 GMA apheresis might be a safe alternative treatment option in UC patients with failure or intolerance to immunosuppressants and TNF inhibitors.

Background: Infliximab is typically administered to patients with inflammatory bowel disease (IBD) using a 2-hour infusion interval. Several studies have shown that shortened infusion intervals are well tolerated and are associated with increased patient satisfaction. The aim of this study was to determine long-term safety and efficacy of accelerated infliximab infusions in a cohort of IBD patients. Methods: A cohort of IBD patients on stable maintenance dosing of infliximab were offered accelerated infusions at our institution. Patients initially received infusions over a 90 minute interval, and if tolerated then continued with 60 minute infusions at each subsequent infusion. Patient demographics, number of accelerated infusions, and acute or delayed infusion reactions were recorded. Results: 44 patients with IBD (24 male, 8 ulcerative colitis) on stable infliximab dosing received accelerated infusions at our institution. A total of 652 accelerated infusions were administered. Median duration of accelerated infusions was 27 months (range 8-35 months). Mild acute infusion reactions were reported in 0.8% (5/652) and did not recur with return to 2 hour infusions. No severe infusion reactions were reported. No patients discontinued infliximab due to loss of response, although adjustments in infliximab dose or frequency occurred in 10 patients during the follow up period. Patient satisfaction with accelerated infusions was high (90%). Conclusion: Accelerated (60 minute) infliximab infusions were safe and well tolerated in our cohort of IBD patients. Accelerated infusions were associated with an acceptably low risk of infusion reaction and were not associated with a significant risk of loss of response over a median of 27 months of follow up. Patient acceptance of accelerated infliximab infusions was high and is consistent with results from prior studies.

Primary squamous cell carcinoma is rarely observed, with a reported incidence of 0.04–0.07 % of all gastric cancers. An 81-year-old male underwent chemoradiotherapy for type 1 gastric cancer of the posterior wall of the cardiac region in 2005. The tumor disappeared after 1 year of therapy, following which an area of white epithelium, approximately 30 mm in diameter and continuous with the esophageal mucosa, became visible. Biopsy of the white epithelium indicated normal squamous epithelium. An elevated lesion was subsequently detected in the area of white epithelium on upper gastrointestinal endoscopy during a follow-up examination 5 years after therapy. As a biopsy of the same site indicated squamous cell carcinoma, we performed endoscopic submucosal dissection. Histopathological examination indicated high-grade fibrosis due to radiotherapy and showed a moderately differentiated squamous cell carcinoma invading the scarred portion. We describe a case where the developmental process of a squamous cell carcinoma was observed using endoscopy, including narrow band imaging with magnification. This carcinoma likely originated from squamous metaplasia that developed after chemoradiotherapy was administered for a gastric cancer.