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An 82-year-old Japanese man underwent esophagogastroduodenoscopy for postprandial epigastric discomfort. The patient was diagnosed with hypozincemia with a serum zinc level of 63μg/dL (normal range:80-130μg/dL), and he had commenced oral intake of zinc acetate 1 month before the esophagogastroduodenoscopy. Endoscopy showed erosions with white-coated mucosa surface adhesions and erythema on the lesser curvature of the gastric body. Moderately differentiated tubular adenocarcinoma was suspected based on the biopsy examination findings;therefore, he was referred to our hospital for further examination and treatment. A repeat endoscopy showed two erosions with white-coated mucosa surface adhesion and erythema on the lesser curvature of the gastric body. However, the lesion location was different from that detected in the initial endoscopy. The biopsy showed no neoplastic changes. Therefore, based on the endoscopic findings and history of oral zinc acetate administration, we diagnosed the gastric mucosal injury as zinc acetate-associated gastric lesions. The cessation of zinc acetate intake resulted in the resolution of gastric lesions. Reassessment of the biopsy specimen from the initial endoscopy revealed erosions, epithelial cells showing infarct-like necrosis, degenerative atypical cells, and necrotic substances, which were misdiagnosed as neoplastic changes. This case highlights the importance of recognizing the typical endoscopic features of a zinc acetate-associated gastric lesion to enable its prompt diagnosis during esophagogastroduodenoscopy.

At the time of colon polyp follow-up, a 46-year-old Japanese woman with a history of invagination, colon polyps, cervical cancer, and breast cancer was suspected of Peutz-Jeghers syndrome and referred. Multiple polyposes of the jejunum were discovered by capsule endoscopy and double-balloon endoscopy, and the resected specimen was diagnosed with hamartoma. During the follow-up, advanced pancreatic cancer-derived from IPMN developed. It is important to remember that multiple cancers can develop in Peutz-Jeghers syndrome.

Gastric emphysema is a rare condition in which gas from a nonbacterial source accumulates within the gastric wall. In this study, we retrospectively analyzed the cases of five patients who were diagnosed with gastric emphysema at the Okayama University Hospital between January 2010 and April 2021, to reveal the clinical features of the disease. Based on their reviews, we revealed that:i) gastric emphysema occurred in hospitalized bedridden patients (n=5), such as those during/after endotracheal intubation (n=3), those undergoing gastric tube placement (n=3), those undergoing percutaneous endoscopic gastrostomy (n=1), and those undergoing treatment for cerebral infarction (n=1);ii) gastric emphysema was accompanied by the accumulation of gas in the portal (n=4) or gastric veins (n=1);iii) gastric emphysema was accompanied by colon wall thickness increase (n=4);iv) esophagogastroduodenoscopy showed redness, erosions, coarse mucosa, and/or ulcers (n=5);v) a clear boundary between the damaged area and the intact mucosa was observed (n=5);vi) the anterior wall of the stomach was less affected (n=4);vii) mucosal damage was predominant in the gastric folds, whereas the furrow of the mucosa was less affected;and viii) treatment with enteral nutrition suspension and the administration of proton pump inhibitors and antibiotics resulted in the recovery of patients from gastric emphysema (n=5). These results indicate that patients with gastric emphysema have distinct clinical, endoscopic, and radiological features. Furthermore, our results show that these patients can be conservatively managed.

A 45-year-old Japanese man presenting with leg purpura, abdominal pain, and arthralgia was diagnosed with IgA vasculitis. His symptoms resolved after the intravenous administration of prednisolone. However, on day 20 of admission, he experienced bloody discharge and hypovolemic shock. The bleeding point was not identified on contrast-enhanced computed tomography scanning. The blood loss was approximately 10800ml and the patient received transfusions of 48 units of concentrated red blood cells, 18 units of fresh frozen plasma, and 30 units of concentrated platelets. Laparotomy and enteroscopy were performed through the incision of the jejunum to detect the bleeding source. Spurting bleeding was observed during the enteroscopy and partial resection of the jejunum was performed. Histopathological examination of the resected specimen revealed large vessels beneath the jejunal ulcer scar, suggesting bleeding from a Dieulafoy's lesion. Leukocytoclastic vasculitis or cytomegalovirus infection was not observed in the resected specimen. Gastrointestinal symptoms in patients with IgA vasculitis usually improve with bowel rest and conservative treatment. Administration of steroids or factor XIII is recommended for patients with severe abdominal pain refractory to conservative management. Rarely, massive bleeding, perforation, intussusception, and/or intestinal obstruction occur in the gastrointestinal tract and these complications affect patients' prognoses. The clinical course in the present patient indicated that severe bleeding from the gastrointestinal tract can occur even after symptom remission in patients with IgA vasculitis. In such cases, prompt treatment, including laparotomy and/or enteroscopy, is essential.

We retrospectively investigated 14 Japanese patients with Peutz-Jeghers (PJ) syndrome who were treated in six hospitals to determine the prevalence of cancer in Japanese patients with PJ syndrome. The study included seven males and seven females. The mean age at the time of diagnosis of PJ syndrome was 28.1 years (range 2-60 years). Hamartomatous polyps were observed in 13 (92.9%) patients, mucocutaneous pigmentation in 11 (78.6%), and positive family history in six patients (42.9%). The mean observation period after the diagnosis of PJ syndrome was 10.1 years (range 0-34 years). Although one patient died of cancer of unknown primary origin, the remaining 13 patients included in the study completed their last follow-up at each hospital. Cancers were detected in six patients (42.9%), including cancer of the uterine cervix (N=3), breast cancer (N=1), duodenal cancer (N=1), transverse colon cancer (N=1), and cancer of unknown primary origin (N=1). One patient presented with both cervical cancer and breast cancer. No patient presented with pancreatic cancer. This study highlights that patients with PJ syndrome are at high risk for intestinal and extra-intestinal cancers, such as uterine and breast cancer. Routine surveillance for intestinal and extra-intestinal malignancies is warranted in patients with PJ syndrome.

A 69-year-old Japanese man underwent successful percutaneous endoscopic gastrostomy (PEG) without any intra-procedural adverse event. However, 3 days postoperatively, he presented with melena and bloody discharge from the gastrostomy tube. Computed tomography revealed gastric emphysema, hepatic portal venous gas, portal vein thrombosis, and swelling of the ascending colon. We administered antibiotics and discontinued enteral feeding; this resulted in resolution of gastric emphysema, hepatic portal venous gas, and portal vein thrombosis and an improvement in the swelling of the ascending colon. To the best of our knowledge, till date, only three patients have been reported to develop gastric emphysema and hepatic portal venous gas after PEG. All previously reported patients were treated with antibiotics and/or discontinuation of enteral feeding, exhibiting recovery within 6-14 days. Although the occurrence of gastric emphysema and hepatic portal venous gas after a PEG procedure is rare, conservative management can ensure recovery in such patients.

A 40-year-old Japanese man with abdominal pain was referred to our hospital. The patient had been diagnosed with Crohn's disease at the age of 21 years and had since then received treatment with mesalazine and had been advocated an elemental diet. About 30 months before his visit to the hospital, he had swallowed a patency capsule, the retention of which in the ileum was subsequently detected on abdominal ultrasonography. The patient was advised to undergo the evaluation of stenosis, but he refused further investigation at that time. Computed tomography scanning performed at our institution revealed stenosis of the ileum and the presence of a high-density material in the proximal side of the stenosis. Double-balloon enteroscopy and enterography with contrast media revealed multiple stenoses of the ileum. The stenotic ileum was surgically resected, and a foreign body was removed. Electron microscopy analysis revealed that the foreign body was the cellophane wall of the PillCam TM patency capsule. Thus, the retention of the cellophane wall of a patency capsule after consumption was diagnosed for the current case on the basis of the study findings.

A 75-year-old man was admitted to our hospital for further examination of swollen lymph nodes and a possible gastric submucosal tumor. He had persistent fever and anorexia. Blood examination showed anemia, thrombocytopenia, and elevated lactate dehydrogenase and soluble interleukin 2 receptor levels. Swollen lymph nodes and splenomegaly were evident on computed tomography, and the submucosal tumor was revealed by esophagogastric endoscopy. Cervical lymph node biopsy and endoscopic biopsy were performed, which revealed a diagnosis of intravascular lymphoma. In Asian countries, patients with intravascular lymphoma often have hemophagocytic syndrome without lesions of the central nervous system or skin, which is called the Asian variant of intravascular lymphoma. In this case, the patient had no indicative lesions and had no evidence of the hemophagocytic syndrome. He also had lymph node swelling and a gastric submucosal tumor, which are rare in intravascular lymphoma. The patient was treated with chemotherapy (R-CHOP;rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisolone), and complete response was demonstrated (based on the Response Evaluation Criteria for Solid Tumours [RECIST] guideline). In cases of possible intravascular lymphoma, gastrointestinal endoscopy and biopsy should be considered because they are a useful diagnostic strategy.

An 83-year-old Japanese man underwent esophagogastroduodenoscopy for screening purposes. He had a medical history of hypertension, chronic kidney disease, chronic heart failure, and chronic myeloid leukemia, and he had been taking the following medications:ferrous citrate, furosemide, spironolactone, tolvaptan, bisoprolol, nicorandil, warfarin, nilotinib, febuxostat, esomeprazole, digestive enzyme complex, ambroxol, carbocysteine, and potassium L-aspartate. Esophagogastroduodenoscopy revealed a brownish speckled pigmentation in the duodenal bulb. Biopsy specimens from the duodenal villi revealed a brown pigment deposition, which appeared bright on scanning electron microscopy. Energy dispersive X-ray spectroscopy and elemental mapping revealed the presence of iron and sulfur in the duodenal villi. Consequently, pseudomelanosis duodeni was diagnosed based on these findings.

A 77-year-old Japanese man underwent endoscopic submucosal dissection twice over a 5-year period for the treatment of two separate early gastric cancers. He had been taking lanthanum carbonate, an orally administered phosphate binder, for 3 years. Esophagogastroduodenoscopy revealed reddish mucosa in the greater curvature and anterior wall of the gastric angle, while granular, white deposits were also observed in some areas of this reddish mucosa. Additionally, biopsy specimens from the gastric mucosa revealed the deposition of fine, amorphous, eosinophilic material, which appeared bright on scanning electron microscopy. Energy dispersive X-ray spectroscopy revealed the presence of lanthanum and phosphate in these bright areas, and elemental mapping confirmed that their distribution was identical to that seen in the bright areas. Based on these findings, the diagnosis of lanthanum phosphate deposition in the gastric mucosa was determined.

Nine cases of mantle cell lymphoma with gastrointestinal involvement were retrospectively reviewed, and their clinical features, including the involved organs, macroscopic forms, treatment methods, and prognoses were evaluated. The involved organs in the gastrointestinal tract were the stomach in 5 cases, the duodenum in 4, the ileum in 5, the cecum in 1, the colon in 4, and the rectum in 2. The macroscopic form of the gastric involvement varied, and included the protruding type in 3 cases, the ulcerated type in one, and the superficial type in one. On the other hand, the macroscopic form of the intestinal involvement from the duodenum to the rectum was mostly of the multiple lymphomatous polyposis type, which was observed in 6 cases. A hyper CVAD/MA regimen and high-dose chemotherapy with autologous peripheral blood stem cell transplantation was performed in 5 cases. All of these 5 cases continue to show a complete response.

A 30-year-old woman was referred to us because of hypoglycemic attack. The tumor on the pancreatic body of 22 mm size was revealed by close inspection, and was diagnosed as insulinoma. Surgical resection was performed, but curative resection was impossible because the component of adenocarcinoma infiltrating into surrounding tissue coexisted with insulinoma. Postoperatively, we make a diagnosis of combined tumor of the pancreas, i.e. mixed duct-islet cell carcinoma. In this paper, we discuss this rare disorder and summarize 33 cases reported in the Japanese literature.