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An epidermoid cyst arising within an intrapancreatic accessory spleen (ECIAS) is rare, and also difficult to correctly diagnose before surgery. It is mostly misdiagnosed as a cystic tumor, such as a mucinous cystic neoplasm or as a solid tumor with cystic degeneration, such as a neuro endocrine tumor. We herein report a case of ECIAS and also perform a literature review of 35 reports of ECIAS. Although the preoperative diagnosis of ECIAS using conventional imaging is relatively difficult to make, careful preoperative examinations of the features on computed tomography and magnetic resonance imaging could lead to a correct preoperative diagnosis of ECIAS which might thereby reduce the number of unnecessary resections.

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An 87-year-old woman on oral prednisolone was diagnosed with a cholecystoduodenal fistula (CDF) caused by a cytomegalovirus-associated duodenal ulcer (DU) and was managed conservatively. A CDF caused by a DU is extremely rare. Although surgical repair is recommended for the treatment of a CDF caused by cholecystolithiasis, appropriate treatment for CDF caused by a DU remains controversial. This case report of a CDF caused by a DU suggests that conservative treatment is feasible in the absence of DU-associated complications, such as an untreatable hemorrhage or obstruction; this finding is compatible with previously reported cases that were conservatively treated.

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Repeated cytology of pancreatic juice obtained by endoscopic nasopancreatic drainage (ENPD) tube has been highlighted as an early diagnostic method for small pancreatic cancer, including carcinoma in situ. We report two cases of early-stage pancreatic cancer diagnosed using repeated cytology; both cases underwent curative resection. No significant masses were found on conventional imaging in either case, with only pancreatic duct strictures being observed. ENPD tubes were placed to collect pancreatic juice in both cases. In case 1, two of five pancreatic juice samples showed adenocarcinoma. Therefore, distal pancreatectomy was performed, and a PanIN3 grade neoplasm (carcinoma in situ) was identified at the branch duct near the distal stricture. In case 2, two of seven pancreatic juice samples (collected during the second tube placement) showed adenocarcinoma. Therefore, distal pancreatectomy was performed, and a PanIN3 neoplasm was identified primarily in the pancreatic duct at a narrow section with fibrosis. Partial microinvasion (<1 mm) was observed at the branch duct. Repeated cytology of pancreatic juice obtained by ENPD tube is effective for early diagnosis of pancreatic cancer, especially in cases without mass formation. However, some issues, including the appropriate number of samples, should be addressed in large prospective studies.

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BACKGROUND & AIMS: It is often difficult to determine the cause of obscure gastrointestinal bleeding (OGIB). We evaluated the diagnostic yield and long-term outcome of patients with OGIB by using double-balloon endoscopy (DBE). METHODS: In this large, retrospective cohort study, DBE was performed in 200 consecutive patients with OGIB. Follow-up data were available from 151 patients for 29.7 months (range, 6-78 months), and clinical outcome was assessed. RESULTS: DBE detected bleeding sources in 155 of 200 patients (77.5%). The most frequent source detected was small intestine ulcers/erosions (64 patients). Patients who underwent DBE within 1 month after the last episode of overt bleeding had a better yield of positive findings than those who did not (84%, 107/128 patients vs 57%, 24/42; P = .002). The overall rate of control of OGIB was 64% (97/151 patients). Patients with vascular lesions of the small intestine had a significantly lower rate of control of OGIB than those with other small intestine lesions (40%, 12/30 patients vs 74%, 52/70; P = .001). A requirement for a large transfusion before DBE (P = .012), multiple lesions (P = .010), and suspicious (not definite) lesions (P = .038) each significantly increased the likelihood of overt rebleeding in patients with vascular lesions of the small intestine. CONCLUSIONS: DBE is useful for the diagnosis of patients with OGIB and should be performed as soon as possible after overt OGIB. Patients with vascular lesions of the small intestine should be followed with particular care.

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BACKGROUND: Although double-balloon enteroscopy (DBE) is performed increasingly often in adults, few findings are available on the use of DBE in pediatric patients in the published literature. OBJECTIVES: The aim of our study was to evaluate the safety and efficacy of DBE in pediatric patients. DESIGN: A retrospective database review. SETTING AND PATIENTS: A database analysis was performed on all pediatric patients (18 years old or younger) who underwent DBE at the Jichi Medical University Hospital between September 2000 and October 2008 selected from a total of 825 patients. MAIN OUTCOME MEASUREMENTS: Clinical utility and safety of DBE in pediatric patients. RESULTS: A total of 92 procedures were performed in 48 patients (27 male, 21 female) with a median age (range) of 12.2 (4-18) years. DBE was performed with the patients under general anesthesia in 43 procedures and under moderate sedation in 49 procedures. The most common indication for DBE was treatment of a stricture of a biliary anastomosis after living-donor liver transplantation with establishment of Roux-en-Y hepaticojejunostomy (23 patients). Endoscopic retrograde cholangiography using DBE was performed, and endoscopic therapy could be performed successfully in 13 (56%) patients. The second most common indication was obscure GI bleeding (10 patients); the lesions responsible for the bleeding were found in 7 (70%) patients. Other indications included surveillance and treatment of hereditary polyposis syndromes (5 patients), abdominal pain (4 patients), and inflammatory bowel disease (2 patients). The overall diagnostic yield was 65% (31 of the 48 patients). Postpolypectomy bleeding occurred in 1 case, but no other complications such as perforation and pancreatitis were observed. LIMITATIONS: Small number of patients, participation bias, and single center's experience. CONCLUSIONS: DBE is a safe and clinically useful endoscopic procedure in pediatric patients.

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Esophageal lymphangioma is a very rare disease. We report a case of esophageal lymphangioma successfully treated with endoscopic submucosal dissection (ESD), which yielded definitive histological diagnosis and symptom relief. ESD offers a better option for definitive diagnosis as well as complete resection of large esophageal lymphangiomas with flat configuration.

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BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) occasionally induce small-bowel injury. However, the clinical features have only been partially clarified. The aim of this study was to clarify the clinical features of the disease and evaluate the effectiveness of endoscopic balloon dilation therapy for diaphragm disease, using double-balloon endoscopy (DBE). METHODS: This is a retrospective case study using our DBE database. Our inclusion criteria required patients to meet all the following criteria: (1) history of NSAID use; (2) endoscopic findings of erosion and/or ulcer and/or typical diaphragm-like strictures; (3) improvement in clinical findings (signs and symptoms) and/or endoscopic findings by cessation of NSAIDs, except for diaphragm disease; and (4) exclusion of other causes (e.g., malignant tumor, inflammatory bowel disease, and infectious disease). The clinical records of patients were investigated. RESULTS: Eighteen patients were included. Sixteen patients showed ulcerative lesions, and the remaining 2 patients showed diaphragm diseases. For localized lesions, 12 patients evidenced lesions in the ileum, 5 patients had lesions in the duodenum and/or jejunum, and 1 had lesions in both intestines. The ulcerative lesions were multiple with various morphologies that were located unrelated to mesenteric or antimesenteric sides. The endoscopic balloon dilations were performed safely, and all patients improved with regard to their symptoms. CONCLUSIONS: Symptomatic NSAID-induced small-bowel injuries exhibit a variety of patterns of ulcerative lesions as observed in the ileum in many cases. The endoscopic balloon dilation appears to be a safe and effective treatment for diaphragm disease.

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Double balloon endoscopy (DBE) was developed as a new technique for visualization and intervention of the entire small intestine. It has been world-widely reported that DBE is very useful for not only diagnosis but also endoscopic therapy. In this chapter, hemostatic procedure, polypectomy, dilation therapy for benign strictures, reduction of intussusception, removal of foreign bodies, and therapeutic ERCP in long-limb surgical bypass patients are described introductively. Diagnostic DBE is thought to be safe with a low complication rate, but it is reported that the complication rate in therapeutic DBE is higher than that associated with colonoscopy. The thin wall of the small intestine can explain this. Endoscopic therapy in the small intestine should be performed with special care to avoid complications such as bleeding and perforation.

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BACKGROUND: The endoscopic diagnosis of depressed-type early gastric cancers is difficult because these cancers manifest as subtle changes in color and shape. The newly developed optimal band imaging (OBI) system can reconstruct the best spectral images derived from ordinary endoscopic images and enhances the mucosal surface without the use of dyes. This imaging technique is based on narrowing the bandwidth of conventional image arithmetically by using spectral estimation technology. OBJECTIVE: Evaluation of the usefulness of the OBI system for identifying the demarcation line of depressed-type early gastric cancers. DESIGN: Prospective study. SETTING: Jichi Medical University in Japan. PATIENTS: Twenty-seven cases with depressed-type early gastric cancer. MAIN OUTCOME MEASUREMENT: Comparative study for the success rate of identifying the demarcation line of depressed-type early gastric cancer by using optimal band images and conventional endoscopic images. RESULTS: Demarcation of the depressed-type early gastric cancer was easily identified by optimal band images without magnification in 26 of 27 cases (96%), because distinct demarcation was observed endoscopically between the reddish images of the cancerous lesion and the yellowish images of the surrounding noncancerous area. With 40-fold magnification of optimal band images, the demarcation was also clearly recognized in all cases. Medical students could point out the demarcation line with significantly greater accuracy by observing the new nonmagnified optimal band images than by the conventional images (P< .0001). LIMITATION: Small sample size. CONCLUSIONS: The new contrasting images of the OBI system can delineate the depressed-type early gastric cancer more easily than conventional endoscopy.

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BACKGROUND: Small-intestinal vascular lesions observed by endoscopy vary in appearance. Angioectasia is a venous lesion that requires cauterization; a Dieulafoy's lesion and arteriovenous malformation may cause arterial bleeding, which requires clipping or laparotomy. For selection of the appropriate treatment, it is necessary to distinguish between venous and arterial lesions. PATIENTS AND METHODS: We classified these lesions into the following 6 groups: type 1a, punctulate erythema (< 1 mm), with or without oozing; type 1b, patchy erythema (a few mm), with or without oozing; type 2a, punctulate lesions (< 1 mm), with pulsatile bleeding; type 2b, pulsatile red protrusion, without surrounding venous dilatation; type 3, pulsatile red protrusion, with surrounding venous dilatation; type 4, other lesions not classified into any of the above categories. Types 1a and 1b are considered angioectasias. Types 2a and 2b are Dieulafoy's lesions. Type 3 represents an arteriovenous malformation. Type 4 is unclassifiable. Three endoscopists independently reviewed images and video to classify 102 vascular lesions into the above types. The rate of concordance among the 3 endoscopists was calculated. RESULTS: Eighty-four lesions (82%) were classified into the same type by all of 3 endoscopists. The mean kappa value (standard deviation) for the concordance was 0.72 +/- 0.07, which confirmed substantial interobserver concordance. LIMITATIONS: This classification is applicable only to endoscopic findings. It was desirable to correlate the histopathologic findings with endoscopic observations. CONCLUSIONS: This classification will be useful for selecting the hemostatic procedure and outcome studies.

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