Introduction: Sedative-analgesic agents are reported to reduce the pain and discomfort of esophagogastroduodenoscopy (EGD), but the specific effects of these agents on examination of the esophagogastric junction (EGJ) are unknown. We conducted a prospective, randomized, double-blind clinical trial in which we compared the effects of midazolam and pethidine hydrochloride on EGJ examination during EGD. Methods: The 32 patients included in the study were chosen from among 80 patients scheduled to undergo EGD at our hospital between February 2016 and May 2018. Patients were randomly allocated to intravenous administration of midazolam (n=16) or pethidine (n=16). The midazolam was administered to patients at the same dose as during the previous examination, whereas the pethidine was administered at a dose of 35 mg. Perfect observation was defined as examination of the full circumferential extent of the EGJ. The primary study endpoint was the percentage of patients in whom perfect observation was achieved. Results: Perfect observation was achieved in six patients (37.5%) in the midazolam group and nine patients (56.3%) in the pethidine group (between-group difference: 18.8%, 95% confidence interval [CI]: -59.0% to 21.5%; P=0.29). The mean extent of EGJ examination was 65.0±38.3% in the midazolam group and 78.6±27.3% in the pethidine group (intergroup difference: -13.6%, 95% CI: -37.8% to 10.3%; P=0.25). The mean visual analog scale score for pain and discomfort during endoscopy was 0.75±2.02 in the midazolam group and 2.25±1.77 in the pethidine group, indicating significantly higher levels of discomfort in the pethidine group (intergroup difference: -1.50, 95% CI: -2.87 to -1.30; P=0.033). There was no between-group difference in the number of procedural accidents or degree of the endoscopists' satisfaction. Conclusion: Midazolam was superior to pethidine in relieving discomfort during EGD, but pethidine tended to be better than midazolam for observing the EGJ.

BACKGROUND/AIMS:A definitive biopsy-based diagnosis of gastric cancer is sometimes difficult, and some cases are pathologically diagnosed as gastric indefinite neoplasia (GIN). The most appropriate forceps size for gastric biopsy has yet to be determined. In this study, we investigated the relation between the forceps size and the frequency of GIN diagnosis. MATERIALS AND METHODS:The records of patients from two historical groups were reviewed. The first group comprised patients evaluated during the period when standard biopsy forceps (StF) were used (April 2010-March 2011), and the second group comprised patients evaluated during the period when small biopsy forceps (SmF) were used (April 2011-March 2013). Patients in whom GIN lesions were diagnosed with biopsy were identified, and pertinent data were compared between the two groups of patients. RESULTS:Among the 8,420 patients who underwent esophagogastroduodenoscopy (EGD) during the first period, 2,584 (30.7%) underwent gastric biopsy with StF. Among the 15,968 patients who underwent EGD during the second period, 4,204 (26.3%) underwent gastric biopsy with SmF. GIN was diagnosed in a significantly greater number of patients in the SmF group than in the StF group (52 [1.25%] vs. 19 [0.73%]; p=0.048). The mean minor-axis lengths of the biopsy samples were 1.50±0.50 mm and 1.38±0.40 mm in the StF group and the SmF group, respectively, with the SmF group samples tending to be shorter (p=0.088). CONCLUSION:Because the SmF use may increase the rate of GIN diagnosis, the use of SmF with a standard-caliber endoscope should be avoided.

We present a rare case of fecaloma, 7 cm in size, in the setting of systemic scleroderma. A colonoscopy revealed a giant brown fecaloma occupying the lumen of the colon and a colonic ulcer that was caused by the fecaloma. The surface of the fecaloma was hard, large and slippery, and fragmentation was not possible despite the use of various devices, including standard biopsy forceps, an injection needle, and a snare. However, jumbo forceps were able to shave the surface of the fecaloma and break it successfully by repeated biting for 6 h over 2 d. The ability of the jumbo forceps to collect large mucosal samples was also appropriate for achieving fragmentation of the giant fecaloma.

OBJECTIVE We evaluated the diagnostic performance of computed tomography (CT) as an initial radiologic test for assessing the optimal timing of colonoscopy in patients with acute lower gastrointestinal bleeding (LGIB) and investigated the effectiveness of contrast-enhanced (CE) CT for detecting colonic diverticular bleeding. METHODS This was a retrospective study of 1,604 consecutive patients who visited or were referred to St. Marianna University Hospital due to acute LGIB and underwent colonoscopy within three months after presentation between September 2004 and December 2012. The clinicopathological data of the subjects were obtained from their medical records. RESULTS Among the 1,604 patients presenting with LGIB, 879 (55%) underwent a CT scan. Elective colonoscopy was considered in cases in which typical colonic wall thickening was observed on CT, suggesting colonic inflammation or malignancy (239 patients; 27%). The diagnoses in the elective cases included ischemic colitis (38%), infectious colitis (8%), inflammatory bowel disease (8%) and malignancy (5%). Urgent colonoscopy was performed after the CT examination in 640 cases (73%). The most common presumptive CT diagnosis was diverticulum (402/640; 63%). Of the 638 patients who underwent CE-CT, diverticula were observed in 346 cases, including 104 cases of extravasation indicating ongoing diverticular bleeding. Among these 104 patients, the site of bleeding was identified in 71 subjects (68%) during colonoscopy. The rate of detection of the bleeding source on colonoscopy was significantly higher in the patients with extravasation on CE-CT than in those without extravasation on CE-CT (68% vs. 20%, respectively; p<0.001). CONCLUSION Urgent CT is useful for determining the optimal timing of colonoscopy in cases of acute LGIB. CE-CT may be used to depict the presence and location of active hemorrhage and provides useful information for subsequent colonoscopy, especially in patients with diverticular bleeding.

症例は27歳，男性。心窩部痛を主訴に近医受診。上部消化管内視鏡にて食道胃接合部に粘膜不整を認め，生検にてGroup 4であり悪性疾患が疑われ当院へ紹介受診となった。当院での上部消化管内視鏡では，NBI拡大観察にて血管蛇行や癒合を伴う異型血管を認め，short segment Barrett’s esophagus（SSBE）より発生したBarrett腺癌が疑われ，診断的治療目的に内視鏡的粘膜下層剥離術を施行した。病理組織学的診断にてBarrett腺癌と診断され，粘膜下層浸潤，脈管侵襲を認めたため追加外科的切除となった。本邦では全食道癌の90％以上が扁平上皮癌であり腺癌は比較的稀である。しかしH. pylori感染率低下，食生活欧米化によるGERD増加に伴い，近年Barrett腺癌の増加が懸念されている。一方，若年者におけるBarrett腺癌の報告は本邦，欧米含め散見されるのみである。今回我々は若年者に発生したBarrett腺癌を経験したので文献的考察を含め報告する。

Giardia lamblia is one cause of prolonged diarrhea in overseas travelers. Demonstration of trophozoites in stool is the traditional method of diagnosis. Here we present a case of giardiasis diagnosed by lavage fluid collected during colonoscopy (CS) .A 60-year-old woman presented at our hospital with prolonged watery diarrhea since travel in Southeast Asia. She had been treated empirically due to negative results from EGD, CS and stool culture. A second CS was performed one year and nine months after the first CS, because the diarrhea persisted. Trophozoites of Giardia lamblia were detected microscopically in lavage fluid sediment collected during this CS. Oral administration of metronidazole (750 mg/day) for one week dramatically improved the patient’s symptoms. This case suggests that CS lavage fluid assessment is a useful method to detect Giardia lamblia in patients with chronic diarrhea.

AIMTo elucidate the colonoscopic features of serrated lesions of the colorectum using magnifying colonoscopy.METHODSBroad division of serrated lesions of the colorectum into hyperplastic polyps (HPs), traditional serrated adenomas (TSAs), and sessile serrated adenomas/polyps (SSA/Ps) has been proposed on the basis of recent molecular biological studies. However, few reports have examined the colonoscopic features of these divisions, including magnified colonoscopic findings. This study examined 118 lesions excised in our hospital as suspected serrated lesions after magnified observation between January 2008 and September 2011. Patient characteristics (sex, age), conventional colonoscopic findings (location, size, morphology, color, mucin) and magnified colonoscopic findings (pit pattern diagnosis) were interpreted by five colonoscopists with experience in over 1000 colonoscopies, and were compared with histopathological diagnoses. The pit patterns were categorized according to Kudo's classification, but a more detailed investigation was also performed using the subclassification [type II-Open (type II-O), type II-Long (type II-L), or type IV-Serrated (type IV-S)] proposed by Kimura T and Yamano H.RESULTSLesions comprised 23 HPs (23/118: 19.5%), 39 TSAs (39/118: 33.1%: with cancer in one case), 50 SSA/Ps (50/118: 42.4%: complicated with cancer in three cases), and six others (6/118: 5.1%). We excluded six others, including three regular adenomas, one hamartoma, one inflammatory polyp, and one juvenile polyp for further analysis. Conventional colonoscopy showed that SSA/Ps were characterized as larger in diameter than TSAs and HPs (SSA/P vs HP, 13.62 ± 8.62 mm vs 7.74 ± 3.24 mm, P < 0.001; SSA/Ps vs TSA, 13.62 ± 8.62 mm vs 9.89 ± 5.73 mm, P < 0.01); common in the right side of the colon [HPs, 30.4% (7/23): TSAs, 20.5% (8/39): SSA/P, 84.0% (42/50), P < 0.001]; flat-elevated lesion [HPs, 30.4% (7/23): TSAs, 5.1% (2/39): SSA/Ps, 90.0% (45/50), P < 0.001]; normal-colored or pale imucosa [HPs, 34.8% (8/23): TSAs, 10.3% (4/39): SSA/Ps, 80% (40/50), P < 0.001]; and with large amounts of mucin [HPs, 21.7% (5/23): TSAs, 17.9% (7/39): SSA/Ps, 72.0% (36/50), P < 0.001]. In magnified colonoscopic findings, 17 lesions showed either type II pit pattern alone or partial type II pit pattern as the basic architecture, with 14 HPs (14/17, 70.0%) and 3 SSA/Ps. Magnified colonoscopy showed the type II-O pit pattern as characteristic of SSA/Ps [sensitivity 83.7% (41/49), specificity 85.7% (54/63)]. Cancer was also present in three lesions, in all of which a type VI pit pattern was also present within the same lesion. There were four HPs and four TSAs each. The type IV-S pit pattern was characteristic of TSAs [sensitivity 96.7% (30/31), specificity 89.9% (72/81)]. Cancer was present in one lesion, in which a type VI pit pattern was also present within the same lesion. In our study, serrated lesions of the colorectum also possessed the features described in previous reports of conventional colonoscopic findings. The pit pattern diagnosis using magnifying colonoscopy, particularly magnified colonoscopic findings using subclassifications of surface architecture, reflected the pathological characteristics of SSA/Ps and TSAs, and will be useful for colonoscopic diagnosis.CONCLUSIONWe suggest that this system could be a good diagnostic tool for SSA/Ps using magnifying colonoscopy.