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Hereditary diffuse gastric cancer (HDGC) is an autosomal dominant cancer caused by CDH1 mutation. HDGC causes multiple signet ring cell carcinomas (SRCCs) throughout the stomach. Few reports exist on the endoscopic findings during screening endoscopy, leading to the diagnosis of HDGC in its early stages. Recently, a new image-enhancement endoscopy technique, texture and color enhancement imaging (TXI), has been developed to improve the visibility of early gastric cancer. To the best of our knowledge, the use of TXI leading to HDGC diagnosis has not been reported. In this report, TXI contributed to the diagnosis of HDGC, and the patient was treated with total gastrectomy. A 27-year-old woman with a family history of gastric cancer underwent esophagogastroduodenoscopy, which revealed two pale lesions in the lower body of the stomach. Histological examination of the biopsy specimen revealed SRCC and the patient was referred to our hospital for treatment. Multiple lesions were found in the lower body using TXI, and a targeted biopsy confirmed other SRCCs. We suspected her disease to be HDGC, and the patient underwent a total gastrectomy. Histopathology showed multiple SRCCs (>60), but no lymph node metastases. Genetic testing revealed CDH1 mutations. The final pathological stage of the tumor was pT1a(m) N0M0 Stage I. TXI may be helpful in detecting multiple SRCCs in patients with HDGC. Endoscopists should be aware of HDGC, and careful investigation of the entire stomach is required for patients with diffuse-type gastric cancer before treatment., Competing Interests: All authors had full access to the data and had the final responsibility for the decision to submit for publication. No benefits in any form have been received or will be received from any commercial party directly or indirectly related to the subject of this study. Author Kazuki Sumiyama is the DEN Open's Deputy Editor‐in‐Chief., (© 2025 The Author(s). DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Objectives: Selection criteria for self-expandable metal stents (SEMSs) with or without cover during palliative treatment of distal malignant biliary obstruction (DMBO) remain unclear. We evaluated factors associated with time to recurrent biliary obstruction (TRBO) in fully covered SEMSs (FCSEMSs) and uncovered SEMSs (UCSEMSs)., Methods: We retrospectively analyzed consecutive patients with DMBO who received a SEMS. TRBO was determined using the Kaplan-Meier analysis, and complications were compared between the FCSEMS and UCSEMS groups. After TRBO-associated factors were extracted using multivariate competing-risks regression (CRR), propensity score-adjusted CRRs were performed to verify their robustness., Results: There were 180 patients (66 FCSEMSs and 114 UCSEMSs) enrolled in this study. There was no significant difference between median TRBO in the FCSEMS and UCSEMS groups (275 vs. 255 days, p = 0.67). Complications were more frequent in the FCSEMS than UCSEMS group (21.2% vs. 8.8%; p = 0.023). Multivariate CRR for TRBO-associated factors revealed that "pancreatic ductal carcinoma (PDAC) treated with UCSEMS" was the only independent predictor of TRBO ( p = 0.03). Similarly, the propensity score-adjusted CRRs showed no significant difference in TRBO in "FCSEMS" vs "UCSEMS" ( p = 0.96); however, there was a significant difference in "PDAC using UCSEMS" vs "other" ( p = 0.043). In the palliative care group including any DMBO without chemotherapy, the first quartile of the TRBO of UCSEMS was 100 days., Conclusions: UCSEMSs are a possible option for both patients with DMBO arising from PDAC and for patients with any DMBO receiving palliative care who should avoid SEMS-related complications., Competing Interests: The author Kazuki Sumiyama is DEIC of DEN Open. The rest of the authors declare that they have no conflict of interest., (© 2022 The Authors. DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has become popular as a new drainage technique for malignant biliary strictures. Although EUS-BD has been reported to show high technical and clinical success rates, the rate of adverse events is 15%. In particular, peritonitis, which is generally caused by bile leakage from the aspiration side during the procedure and occurs within a few days after EUS-BD, needs to be considered as it can be fatal. In the present case, a jaundiced patient presented with unresectable pancreatic adenocarcinoma. Due to duodenal invasion, we performed EUS-guided hepaticogastrostomy for biliary drainage. After the procedure, jaundice improved, and abdominal computed tomography (CT) showed only a small amount of air in the intrahepatic bile duct. However, 7 days after the procedure, the patient developed fever, and clinical findings indicated peritonitis. Abdominal CT showed food in the stomach accompanied by the appearance of perihepatic free air, with increased air in the intrahepatic bile duct. The duodenal stent insertion settled the peritonitis and improved the perihepatic free air and the air in the intrahepatic bile duct through the discharge of food from the stomach. To date, no case of tardive peritonitis associated with air leakage after EUS-BD has been reported. We noted that even if there was no evidence of bile leakage after EUS-BD, the possibility of tardive peritonitis due to gradual air leakage from the stent implantation side of the stomach should be considered, and careful follow-up is needed., Competing Interests: All authors had full access to the data and had final responsibility for the decision to submit for publication. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Kazuki Sumiyama is a Deputy Editor‐in‐Chief of DEN Open., (© 2021 The Authors. DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)