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Background and Aim: Small gastric subepithelial lesions (SELs) are sometimes encountered in daily esophagogastroduodenoscopy (EGD) practice, but whether once-annual or twice-annual endoscopy can provide sufficient follow-up remains unclear. Because follow-up based on small-SEL characteristics is important, this study clarified the natural history of gastric SELs less than 20 mm. Methods: This retrospective multicenter observation study conducted at 24 Japanese hospitals during April 2000 to March 2020 examined small gastric SELs of ≤20 mm diameter. The primary outcome was the rate of size increase of those SELs detected using EGD, with growth times assessed irrespective of SEL pathological diagnoses. Results: We examined 824 cases with tumors of 1–5 mm diameter in 298 (36.2%) cases, 6–10 mm in 344 (41.7%) cases, 11–15 mm in 112 (13.6%) cases, and 16–20 mm in 70 (8.50%) cases. An increase of small gastric SELs was observed in 70/824 patients (8.5%). The SELs larger than 6 mm increased, even after 10 years. No-change and increasing groups had no significantly different malignant findings at diagnosis. In cases of gastrointestinal stromal tumors (GISTs), internal cystic change in endoscopic ultrasound (EUS) is a risk factor for an increased tumor size. The predictive tumor growth cutoff size at initial diagnosis was 13.5 mm. Conclusions: Small gastric SELs less than 20 mm have an approximately 8.5% chance of increase. Predictive markers for GIST growth are tumor size ≥13.5 mm and internal cystic change in EUS.

Photodynamic therapy is useful as organ-preservation salvage therapy for residual recurrence of esophageal squamous cell carcinoma after chemoradiation therapy. However, the high residual recurrence rate of photodynamic therapy poses a problem. We herein report a patient who underwent photodynamic therapy for recurrence of superficial esophageal squamous cell carcinoma after chemoradiation therapy. The patient later exhibited another episode of recurrence of superficial esophageal squamous cell carcinoma, and R0 curative resection was obtained with endoscopic submucosal dissection. This suggests that endoscopic submucosal dissection may be an effective treatment option that can achieve R0 resection even for residual superficial cancer after salvage photodynamic therapy.

We report about a patient with an extremely rare long-segment Barrett’s esophagus (LSBE) who developed extensive superficial adenocarcinoma and underwent radical (R0) resection based on an accurate preoperative diagnosis of tumor extent. A 68-year-old man with no subjective symptoms and no noteworthy medical history was diagnosed with adenocarcinoma after a biopsy of a protruding lesion in the lower esophagus. Narrow-band imaging (NBI) magnification endoscopy revealed that the protruded lesion was within the LSBE, and a flatly extended superficial esophageal adenocarcinoma (SEAC) was observed proximal to the protruded lesion. After confirming the extent of the tumorous lesion via endoscopic biopsy, subcircumferential endoscopic submucosal dissection (ESD) was performed for the extensive tumor, which resulted in a histological R0 resection. Prophylactic steroid therapy was performed to prevent refractory post-ESD stenosis. There was no residual tumor or recurrence of the cancer, and the patient’s postoperative course was favorable. Preoperative diagnosis of tumor extent using NBI magnification endoscopy may therefore be useful for characterizing SEAC occurring in the LSBE, given that detecting the presence and determining the extent of these tumors is normally difficult. Prophylactic therapy with local steroid injection can prevent refractory stenosis after quite extensive ESDs for SEACs in the LSBE.

Polyethylene glycol is a safe agent for bowel cleansing in preparation for colonoscopy. However, it can cause considerable electrolyte abnormalities. We herein report two cases of hyponatremia because of bowel preparation using polyethylene glycol. Case 1: The patient, a man in his 70s, was admitted to our hospital for an endoscopic mucosal resection of an adenoma of the large intestine. After the preparation, the patient developed consciousness disturbance. His serum Na level was 122 mEq/L, indicating a marked degree of electrolyte abnormality. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) was inferred as the cause of hyponatremia. Case 2: A patient in his 70s, based on a positive fecal occult blood test result, was scheduled to undergo colonoscopy. A blood test on the day of the colonoscopy showed his serum sodium level as 107 mEq/L. The patient was found to have chronic hyponatremia, which prevented development of clinical symptoms. However, because of preservation of ADH secretion despite the hyponatremia, a diagnosis of SIADH was made. These cases suggest that clinicians should be aware of the risk of hyponatremia during bowel preparation for colonoscopy.

Background: Endoscopic ultrasound-guided puncture aspiration biopsy (EUS-FNA) of pancreatic ductal adenocarcinoma (PDAC) is highly diagnostic, but it is difficult to distinguish from benign disease. Our objective was to determine the usefulness of maspin staining, in addition to conventional p53 staining, in the diagnosis of PDAC by EUS-FNA. Methods: Of the patients who underwent EUS-FNA and were diagnosed with PDAC, we retrospectively identified 90 cases in which both maspin and p53 staining were performed. In addition, we identified 28 cases of benign pancreatic disease diagnosed using EUS-FNA and these were selected as a control group. For analysis of EUS-FNA specimens, Cohen’s Kappa (κ) coefficient and the prevalence and bias adjusted Kappa statistic (PABAK) were applied to assess the significance of sensitivity and specificity, comparing p53, maspin, p53+maspin. Results: The sensitivity and specificity of p53 staining were 48.9% and 100%. The κ coefficient was 0.31 (95%CI 0.18–0.44) (p < 0.01) and the PABAK coefficient was 0.22 (95%CI 0.03–0.40). The results for maspin staining were 88.9% and 92.9%. The κ coefficient was 0.72 (95%CI 0.54–0.90) (p < 0.01) and the PABAK coefficient was 0.78 (95%CI 0.64–0.88). The results for the combination of maspin and p53 staining were 94.4% and 92.2%. The κ coefficient was 0.82 (95%CI 0.64–1.00) (p < 0.01) and the PABAK coefficient was 0.86 (95%CI 0.74–0.94). Conclusion: Adding maspin staining to p53 staining showed high sensitivity and specificity. Our results demonstrated the usefulness of their combined use that might contribute to the improvement of tissue diagnostic performance of PDAC by EUS-FNA.

Advanced endoscopy (AVE) techniques include image-enhanced endoscopy methods, such as narrow-band imaging (NBI), and types of microscopic endoscopy, such as endocytoscopy. In the esophagus, AVE first showed diagnostic utility in the diagnosis of superficial esophageal cancer and was then applied to inflammatory disease. This review focuses on non-erosive reflux disease (NERD) and eosinophilic esophagitis (EoE), which sometimes show no abnormal findings on standard white light endoscopy alone. Studies have demonstrated that advanced endoscopy, including NBI magnification endoscopy and endocytoscopy, improved the diagnostic performance of white-light endoscopy alone for NERD and EoE. In this review, we explain why advanced endoscopy is needed for the diagnosis of these esophageal inflammatory diseases, summarize the study results, and discuss future perspectives.

Endoscopic ultrasound (EUS) is widely recognized for its non-invasiveness and for its usefulness in chronic pancreatitis (CP) diagnosis, including early CP. Although it is desirable to obtain a definitive diagnosis of CP by tissue sampling with EUS-guided fine needle aspiration, histopathological changes in CP are heterogeneous in terms of the extent and the distribution of lesions. Therefore, histopathological diagnosis of appropriate tissue sampling by EUS-fine needle aspiration is expected to be difficult. Furthermore, it is virtually impossible to match EUS images with pathological sections, making direct contrast between EUS findings and pathology difficult. This narrative review presents a discussion of the diagnosis of CP/early CP by EUS, particularly assessing the association between ultrasound and pathological findings. Recently, the histological corroboration and correlation of EUS findings related to CP have been clarified by surgical specimens, including those obtained from animal studies. Furthermore, remarkable advances have occurred in the objective and quantitative diagnosis of pancreatic fibrosis by EUS-elastography. Future technological advances in EUS are expected to improve the accuracy of diagnosis of pancreatic fibrosis at earlier stages.

Background: According to the mechanistic definition, the history of acute pancreatitis (AP) is a risk factor for chronic pancreatitis (CP). However, the etiology and severity of previous AP involved in the progression to CP have not been clarified. Here, we investigated risk factors for the progression to CP in patients with past-history of AP. Methods: Sixty-four patients with AP who were followed-up for at least two years at our institution between April 2009 and March 2017 were enrolled. The multivariate analysis was performed based on the risk factors extracted by univariate analysis. Results: Among the 64 patients, 13 patients (20.3%) progressed to CP (PCP group), while 48 did not (non-PCP group). Regarding the etiology of AP, rate of alcohol AP was significantly higher in the PCP group (76.9% vs. 33.3%, p = 0.003). In univariate analysis, smoking, number of previous AP, and alcohol consumption and drinking habits (Alcohol Use Disorders Identification Test-Concise; AUDIT-C) were identified as factors associated with progression to CP. Furthermore, multivariate analysis showed that AUDIT-C ≥ 6 points (male) and 4 points (female) after AP was a significant risk factor for CP (p = 0.003). Conclusions: Our results indicated that AUDIT-C ≥ 6 points (male) and 4 points (female) after AP was a risk factor in the process of progression to CP in patients with past-history of AP.

Red color sign-positive (RC-positive) esophageal varices present a high bleeding risk, necessitating prophylactic treatment. Among RC-positive esophageal varices, those classified morphologically as small straight varices (Form level 1: F1) are difficult to treat. Moreover, the appropriate time for therapeutic intervention remains undefined. This study assessed the bleeding risk in RC-positive F1 esophageal varices. After extracting 541 cases of F1 esophageal varices diagnosed during 1 January 2012–29 February 2020, 76 cases of RC-positive F1 esophageal varices were divided into two groups in terms of treatment intervention at diagnosis: 49 cases with (treatment group) and 27 cases without (follow-up group). We assessed the bleeding rates, bleeding-associated factors, and early-bleeding-associated factors. The treatment group’s bleeding rate was 10% (5/49). The follow-up group’s bleeding rate was 78% (21/24). The subsequent bleeding rate was low in the treatment group (p < 0.001). The median period of sustained absence of bleeding was longer in the treatment group than in the follow-up group (1156 [274–1582] days vs. 105 [1–336] days; p < 0.001). In the follow-up group, a significant number of bleedings had varices that included a hematocystic spot (HCS) as RC or combined with RC (p = 0.017). Early bleeding occurred often in varices that included HCS or combined with RC (p = 0.024). Red wale marking (RWM) only was not a factor of early bleeding (p = 0.012). In conclusion, RC-positive varices should be treated even as F1 varices. Patients with RWM only show the possibility of not accepting early treatment intervention. A fast response is crucially important in HCS cases because of its associated bleeding and early bleeding.