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BACKGROUND Although the prevalence of gastroesophageal reflux disease (GERD) has been increasing in Japan, little is known about the prevalence and severity of GERD in pediatric patients. This study compared the prevalence and severity of endoscopically proven GERD in pediatric patients seen at an endoscopy center in Japan over a 15-year period. METHODS This was a retrospective chart review of Japanese children aged 5-18 years undergoing esophagogastroduodenoscopy for upper gastrointestinal symptoms or anemia between 2005 and 2019. The prevalence and severity of reflux esophagitis and endoscopic Barrett's esophagus were compared between the periods 2005-2012 and 2013-2019. RESULTS A total of 564 patients were evaluated: 315 from 2005 to 2012 (mean ± SD) age 13.8 ± 3.0 (range, 5-18 years; 147 boys; and 249 from 2013 to 2019 (mean ± SD) 14.7 ± 2.8 (range, 5-18) years; 108 boys. Demographics and clinical features were similar between the two groups. The proportion with erosive esophagitis or endoscopic Barrett's esophagus increased significantly between the two periods (9.8% to 18.1% for GERD, P = 0.0045 and 2.5% to 9.6% for Barrett's esophagus, P = 0.0003). The proportion of GERD patients with endoscopic Barrett's esophagus also significantly increased between the two periods (24/45 [53.3%]) vs (8/31 [25.8%]), P = 0.017]. CONCLUSION The prevalence and severity of endoscopically proven GERDs has significantly increased over the past 15 years at an endoscopy center in Japan. Detailed population-based studies are needed to assess whether this is occurring throughout Japan.

BACKGROUND Nodular gastritis is most often one of the manifestations of Helicobacter pylori (H. pylori) infection, which is a risk factor for gastric cancer. This study aimed to determine if the histological characteristics of nodular gastritis differed across classes of age. METHODS We conducted a retrospective analysis of consecutive patients who had undergone esophagogastroduodenoscopy with multiple mucosal biopsies of the stomach between 2003 and 2019 for evaluation of updated Sydney System scores. We analyzed and compared the histological characteristics of pediatric (≤15 years old), young (16-29 years old), and older (≥30 years old) patients. RESULTS Of the 1321 patients enrolled, 1027 patients (78%) had H. pylori infection, with 214 patients (21%) of them displaying nodular gastritis. Among nodular gastritis patients, mononuclear cell infiltration Sydney System scores in the gastric body were significantly higher in the older group than in the pediatric (p

A 13-year-old girl presented with sudden-onset colicky abdominal pain and biliary vomiting. She was diagnosed with Peutz-Jeghers syndrome 2 months previously based on mucocutaneous pigmentation and hamartomatous polyposis. On diagnosis of Peutz-Jeghers syndrome, in addition to colonoscopy and esophagogastroduodenoscopy, antegrade and retrograde double-balloon enteroscopies were performed, and >10 hamartomas were resected. She was scheduled for additional elective double-balloon enteroscopy for total small-bowel observation. On visiting the emergency unit, enhanced abdominal computed tomography showed jejuno-jejunal intussusception with a polyp. There were no ischemic signs in the invaginated bowel. Urgent antegrade double-balloon enteroscopy performed 5 hours after onset of acute abdominal symptoms revealed a large polyp with intussusception stalk in the jejunum, and simultaneous reduction of intussusception and endoscopic mucosal resection of the polyp were performed successfully. There were no endoscopy-related complications, and emergent laparotomy was avoided. The patient has been asymptomatic, and total gastrointestinal screening is scheduled every 2 years. This is the first case in which emergent laparotomy was avoided by urgent double-balloon enteroscopy in an adolescent with symptomatic jejuno-jejunal intussusception. Non-surgical management of small-bowel polyps in pediatric patients with Peutz-Jeghers syndrome is beneficial as laparotomy can cause bowel adhesion and increases risk of incomplete balloon-assisted enteroscopy.

Human intestinal spirochetosis (HIS) is a condition in which spirochetes attach to and colonize the colorectal epithelium. To our knowledge, no comprehensive studies of HIS in young patient have been published in a developed country. This study aimed to determine the incidence and clinicopathological manifestations of HIS in Japanese patients aged less than 20 years. We retrospectively reviewed 3605 biopsy and 92 surgical specimens obtained from 479 patients admitted to Shinshu University Hospital between 1997 and 2014. All slides were reviewed independently by two pathologists to confirm the histological presence of spirochetes. Among 387 patients who underwent biopsy, the most common pathologic diagnosis was ulcerative colitis (12.6%, n = 49). Additionally, about half of the biopsy specimens showed non-specific, mildly inflamed mucosa (50.6%, n = 196); only one of these cases was HIS. On the other hand, among the surgical specimens, we found no cases of HIS. We concluded that the incidence of HIS in Japanese young patients was 0.2% (1/479 cases). The incidence of HIS in Japanese young patients was very low, and one HIS case was associated with colitis with abdominal pain.

Intussusception is a frequent and severe complication of Peutz–Jeghers syndrome (PJS). We herein present the case of a 3-year-old girl who experienced jejuno-jejunal intussusception due to PJS polyps. Despite no apparent family history of PJS, she had exhibited mucocutaneous pigmentation since infancy and recurrent abdominal pain and vomiting from 2 years of age. Segmental resection of the jejunum during emergency laparotomy for the intussusception revealed multiple hamartomatous polyps. Genetic analysis uncovered a germline nonsense mutation of c.247A>T in exon 1 of serine/threonine kinase 11 (STK11). Biannual follow-up surveillance for polyps by esophagogastroduodenoscopy, colonoscopy, and small bowel capsule endoscopy is ongoing. Reports describing the clinical and genetic features of extremely young PJS with intussusceptions are rare, although a literature review of STK11 germline mutations revealed several other pediatric cases of complicating intussusception at ≤ 8 years old. Considering the recent advances in surveillance and treatment options for the small bowel, earlier management of symptomatic children with PJS may be warranted to avoid surgical emergency.

BACKGROUND Previously, we conducted an epidemiological study screening for Helicobacter pylori antibody positivity among Japanese junior high school students. In this study, we updated the epidemiological data and assessed the clinical features of H pylori antibody-positive junior high school students. MATERIALS AND METHODS We assessed H pylori antibody-positive subjects who were identified between 2012 and 2015 at four junior high schools in Nagano Prefecture, Japan. H pylori infection was confirmed by urea breath test (UBT) or endoscopic examination. Endoscopy was performed after obtaining consent from the subject and their guardians. Eradication therapy consisted of triple therapy with proton pump inhibitor (PPI), amoxicillin (AMPC), and clarithromycin (CAM) or metronidazole (MNZ) for seven days. Eradication of H pylori was confirmed by UBT. We reviewed subjects' characteristics, endoscopic findings, histological findings, eradication regimes, outcomes, and adverse effects. RESULTS The overall prevalence of H pylori antibody positivity was 3.2% (42/1298). We assessed thirteen H pylori antibody-positive subjects. Eight subjects had a family history of H pylori infection. Six subjects had abdominal pain, and two subjects had iron deficiency anemia (IDA). Twelve subjects underwent endoscopy; one subject had duodenal ulcer, eleven subjects had antral nodular gastritis, and six subjects showed grade 2 closed type atrophic border according to the Kimura-Takemoto classification. All subjects received eradication therapy; CAM was used in five subjects with CAM susceptibility as well as in three subjects with unknown information on CAM susceptibility, and MNZ was used in five subjects with CAM resistance. Eradication was successful in twelve subjects (one unconfirmed). There were three mild adverse effects (abdominal pain or diarrhea). CONCLUSIONS Helicobacter pylori test for junior high school students represents an opportunity to diagnose the peptic ulcer, iron deficiency anemia, and gastric atrophy.

Background There have been few reports on Helicobacter pylori (H. pylori) infection in asymptomatic Japanese children and adolescents. We hypothesized that the prevalence of H. pylori infection is very low among Japanese children and that clinical variables such as serum pepsinogen and iron levels are associated with H. pylori infection. Materials and Methods We conducted a cross-sectional analysis of a sample of 454 junior high school students aged 12-15 years in four areas in Nagano Prefecture. A commercial ELISA kit (E-plate Eiken H. pylori antibody) was used to measure IgG antibody against H. pylori. Serum pepsinogen and iron levels were also measured using standard methods. A urea breath test was performed for seropositive students. Results The overall prevalence of H. pylori was 3.1% (14/454). There were no significant differences in H. pylori prevalence among mountain, rural, and urban areas. The mean level of both serum pepsinogen (PG I) and PG II was significantly increased in the seropositive subjects compared with the seronegative subjects. When the cutoff values for adults (PG I: 70 ng/mL and PG I/II ratio: 3) were used, 4 of 14 subjects had PG I ≤70 ng/mL and PG I/II ratio ≤3. The results of a logistic regression analysis showed that low serum iron levels were significantly associated with H. pylori infection (P=.02). Conclusions The prevalence of H. pylori infection is as low as 3% among junior high school students aged 12-15 years in Japan. The disappearance of H. pylori is accelerating in Japanese children.

Colonoscopy is widely used to detect colorectal cancer and to remove precancerous lesions to reduce the risk of colonic cancer. To examine the benefits and limitations of cap-fitted colonoscopy compared to conventional colonoscopy in terms of technical performance and colorectal adenoma detection rate. Screening colonoscopies performed from 2009 to 2010 with or without a transparent cap were retrospectively examined to compare the rate of successful intubation, cecal intubation time, and number, size, shape, and location of adenomas detected. An inclusion criterion was visualization of >95 % of the right colon. Data from 2,301 colonoscopies (1,165 with cap-fitted colonoscopy, 1,136 without the transparent cap) were retrospectively analyzed. Procedures were performed by four experienced endoscopists. The subjects’ demographic characteristics and technical performances were similar between the two methods. The only significant difference in the technical performance between the two techniques was a shorter cecal intubation time with cap-fitted colonoscopy (5.3 vs. 6.6 min; p = 0.045) by one endoscopist. The total number of adenomas detected was significantly higher with cap-fitted colonoscopy than without the cap (586 vs. 484, respectively; p

Aim Colonoscopy may need to be rescheduledbecause of inadequate bowel preparation. We evaluatedthe effectiveness of colonoscopic enema as rescue foran inadequate 1-day bowel preparation before colonos-copy.Method Patients referred for afternoon colonoscopywere prospectively enrolled in the study during a 1-yearperiod. Patients took bowel preparation (polyethyleneglycol) solution on the morning of the endoscopy. Ifduring colonoscopy the bowel preparation was poor, anenema of polyethylene glycol solution (500 ml) wasinstilled into the colon at the level of the hepatic flexurevia the biopsy channel of the colonoscope which was thenremoved. The patient was allowed to recover from thepropofol sedation and used the bathroom to evacuatethe enema. The colonoscope was then introduced and theexamination continued.Results Of 504 patients undergoing colonoscopy, 26(4.9%) received an enema. The median age was 59(29–79) years and 19 (73%) were female. A subsequentsuccessful colonoscopy was achieved in 25 ⁄26 (96%).There were no complications. The mean time spent forthe entire colonoscopy from the initial preparation to theend of the examination including the enema was7.6 ± 1.1 h (5.4 h preparation, 0.2 h first colonos-copy + enema, 0.66 h waiting in the lavatory, 0.33 hsecond colonoscopy and 1 h for recovery).Conclusion Colonoscopic enema was highly successfulas rescue for patients with inadequate bowel preparationand avoided postponement of the procedure.Keywords Colonoscopy, bowel cleansing, enemaWhat is new in this paper?An enema given down the biopsy channel of thecolonoscope was highly successful as rescue in patientswith inadequate bowel preparation. It avoided postpone-ment of the procedure in 25 out of 26 patients whounderwent the procedure.

Aim Colonoscopy provides imperfect protection againstcolorectal cancer (CRC).In an attempt to improve cancer detection we evalu-ated the clinical features of invasive CRC detected within5 years of a negative colonoscopy.Method The details of colonoscopies performed in arural hospital in Japan were prospectively recorded at thetime of the examination. The patients were followed over5 years for the subsequent occurrence of cancer.Results In a 5-year period, 10 148 patients underwentcolonoscopy and 202 without previous colonoscopy werediagnosed with invasive CRC. Of 3212 patients with acolonoscopy negative for cancer, nine developed invasivecancer within 5 years. The ratios for invasive CRCdetected without ⁄with previous colonoscopy were 60:1in the rectum, 54:1 in the sigmoid colon, 15:1 in thedescending colon, 28:0 in the transverse colon, 31:5 inthe ascending colon and 14:1 in the caecum (P = 0.041).The ratio between left- and right-sided colonic cancer wasalso significantly different (129:3 and 45:6, P = 0.0078).Six (67%) of the invasive CRCs were in the ascendingcolon or caecum. Five of six patients with invasive CRC inthe ascending colon and caecum had right-sided smalladenomas at prior colonoscopy.Conclusion The majority of early ⁄missed CRCs wereright-sided and associated with prior right-sided colonicadenomas. Repeated colonoscopy of patients with right-sided adenomas at a shorter surveillance interval deservesconsideration.Keywords Colorectal cancer, colonoscopy, colonWhat is new in this paper?The majority of early ⁄missed colorectal cancers after anegative colonoscopy are right-sided and associated withthe presence of small adenomas in the area of the priorcolonoscopy. Improved methods for detecting small orflat lesions in the right-sided colon may reduce invasivecolorectal cancer after negative colonoscopy. The surveil-lance interval for those with right-sided adenomas shouldbe reconsidered.

Aim Endoscopic decompression of malignant colorectalobstruction is often dealt with using expandable metallicstents. Endoscopic decompression of benign large bowelobstruction is more difficult. We report the techniqueand outcome of transanal endoscopic decompression forbenign large bowel obstruction.Method From January 2001 to June 2010, endoscopicdecompression using a transanal drainage tube placementwas attempted in consecutive patients with benign largebowel obstruction. The clinical features, technical suc-cess, complications, treatment after the tube placementand clinical success were retrospectively evaluated.Results There were 13 patients (seven males, age 47–87,mean 69 years). The sites of obstruction were transversecolon [5 (38%)], sigmoid colon [3 (23%)], ileocecal valve[2 (15%)], splenic flexure [1 (8%)], descending colon [1(8%)] and rectum [1 (8%)]. The most common cause ofobstruction was anastomotic stricture [9 (69%)]. In 12(92%) patients transanal decompression was technicallysuccessful with one perforation. An overtube, the rein-sertion of colonoscope along the decompression tube, orthe use of a small-diameter endoscope was required forthe tube placement in seven (54%). In seven (54%)patients tube placement alone resulted in relief of bowelobstruction without operation.Conclusion Endoscopic decompression using a transanaldrainage tube is effective for the management of benignlarge bowel obstruction.Keywords Benign large bowel obstruction, colonos-copy, transanal drainage tubeWhat is new in this paper?Endoscopic decompression using expandable metallicstents is often difficult in benign large bowel obstructiondue to migration, bleeding or even perforation. Atechnique is described in which a simple tube was usedfor the treatment of obstructing benign strictures invarious locations of the colon, with relief with a lowcomplication rate, thereby avoiding the need for sub-sequent operation.

BACKGROUND & AIMS: Colonoscopy, using either a transparent retractable extension device or narrow band imaging, is thought to improve colon adenoma detection. We compared the abilities of a transparent retractable extension device and narrow band imaging to detect colorectal adenomas. METHODS: One hundred and seven patients with colonic adenomas that were detected by traditional colonoscopy were randomly assigned to groups that underwent a second colonoscopy that used either a transparent retractable extension or narrow band imaging; adenomas were removed. The principal outcome parameters were the number, size, shape, and location of adenomas detected. The patients’ demographic characteristics, indications for colonoscopy, and cecal intubation times were similar between groups. RESULTS: Use of the transparent retractable extension resulted in detection of 31% more adenomas than the initial procedure (P .0001). The majority of newly discovered adenomas were sessile (79%; 26/33) and less than 5 mm in size (73%; 24/33). There was no significant increase in adenoma detection (5%) between first colonoscopy and second colonoscopy using narrow band imaging. Additional adenomas were found in 40.7% of patients that were examined using the transparent hood (22/54) versus 13.2% of those examined using narrow band imaging (7/53) (P .0028). CONCLUSIONS: Colonoscopy with a transparent retractable extension significantly improved the adenoma detection rate compared with repeat colonoscopy using narrow band imaging.

Background: Recently, quality as well as acceptability has been a concern regarding endoscopy. The aim of the present study was to compare the acceptability and quality of sedated high-definition esophagogastroduodenoscopy (sHD-EGD) using a newly developed high-definition videoscope with those of unsedated ultrathin esophagogastroduodenoscopy (uUT-EGD) using a 5.2 mm videoscope. Methods: Twenty-two volunteers underwent both peroral sHD-EGD and transnasal uUT-EGD on the same day. Sedation consisted of 40 mg of propofol i.v. Both endoscopist and subject satisfaction levels were assessed using a 10 cm visual analogue scale. Results: All 22 subjects completed the sHD-EGD and 21 subjects completed the uUT-EGD. The endoscopist and subject satisfaction levels of sHD-EGD were significantly better than those of uUT-EGD (overall endoscopist satisfaction: 9 vs 4, P

Background and Aim: There are only a few studies on propofol sedation for very elderly patients. The present study was undertaken to evaluate the safety of propofol sedation in patients 90 years of age and older undergoing endoscopic procedures. Methods: We prospectively assessed endoscopic procedures for patients 90 years of age and older using propofol sedation. Endoscopic procedures, dosage used, respiratory depression, complications and 30-day mortality were evaluated. In a subset of the enrolled patients, the blood concentrations of propofol were measured. Results: All 241 patients completed endoscopic procedures. For esophagogastroduodenoscopy, percutaneous endoscopic gastrostomy, colonoscopy, and endoscopic retrograde cholangiopancreatography, the mean propofol doses used were 22, 24, 46 and 42 mg, respectively. Four patients required oxygen and 1 patient was treated by short periods of mask ventilation. There was no perforation, bleeding, pancreatitis or 30-day mortality. In diagnostic esophagogastroduodenoscopy, the level of sedation and propofol blood concentrations after administration of propofol (24 ± 6.8 mg) in patients 90 years of age and older corresponded to those of propofol (61 ± 13 mg) in middle-aged patients (control). Conclusion: Low-dose propofol sedation is safe and may be enough for patients 90 years of age and older undergoing endoscopic procedures.

Background & Aims: Therapeutic endoscopic retrograde cholangiopancreatography requires selective cannulation of the relevant ductal system. The aim of this study was to evaluate the efficacy and safety of 3 different precutting techniques for difficult bile duct access on the basis of the characteristics of the major duodenal papilla (MDP). Methods: The patients were classified into small MDP, large MDP, or swollen MDP groups on the basis of the characteristics of the MDP. The precutting technique was based on MDP characteristics: transpancreatic sphincterotomy for small MDPs, needle-knife precut sphincterotomy for large MDPs, and needle-knife fistulotomy for swollen MDPs. The success rate of bile duct cannulation and the complication rates were compared. Results: A total of 86 patients (58 men; mean age, 76 years) with difficult bile duct cannulation required precutting technique; 48 had transpancreatic sphincterotomy, 30 had needle-knife precut sphincterotomy, and 8 had needle-knife fistulotomy. With precutting, the procedure was successful in 46 of 48 (96%), 27 of 30 (90%), and 8 of 8 patients (100%), respectively. The overall success rate of biliary cannulation after 2 endoscopic retrograde cholangiopancreatography attempts was 100%. The overall complication rate was 4.7% (4 of 86) (2 mild bleeding and 2 mild pancreatitis). Conclusions: Selection of the precutting technique on the basis of the characteristics of the MDP resulted in a high degree of success and a low complication rate in cases of difficult bile duct cannulation.

Objective.To assess anxiety among pediatric patients and their parents related to initial gastrointestinal endoscopy.Methods.Patients aged Results.The subjects were 128 children, aged 1 month to 17 years. Forty-eight patients (37.5%) underwent esophagogastroduodenoscopy (EGD), 32 (25%) underwent colonoscopy (CS), 39 (30.5%) underwent both EGD and CS, 3 (2.3%) underwent balloon enteroscopy (BE), 3 (2.3%) underwent capsule endoscopy (CE), and 3 (2.3%) underwent CE and other endoscopic procedures. In the preendoscopy questionnaire, the most common concerns of the patients and parents before undergoing the procedure were “Pain” (45% of the patients underwent EGD or BE via the oral approach, and 52% of the patients underwent CS or BE via the anal approach) and “Procedural accidents related to the endoscopy” (63% of parents). In the postendoscopy questionnaire, the most common difficulty that patients and parents actually experienced before and after undergoing the procedure was “Hunger.”Conclusion.A preparatory intervention including an explanation regarding specific concerns before initial GI endoscopy, which this study revealed, could reduce anxiety experienced by both pediatric patients and parents.

Background and Aim. The stool antigen enzyme immunoassay (EIA) methods are widely used for diagnosing Helicobacter pylori infection. Recently, a novel, rapid stool antigen test, the lateral flow immunoassay (LFI) method, has been developed. The primary purpose of this study was to compare the EIA method with the LFI method for the diagnosis of H. pylori infection in children. Materials and Methods. Stool specimens from children being evaluated for H. pylori infection were also examined using the LFI (ImmunoCard STAT! HpSA) and EIA methods (Premier Platinum HpSA). The sensitivity, specificity and accuracy of the test were based on the 13C-labeled urea breath test. Results. One hundred and eighty-two children and adolescents, 3–17 years of age (mean 9.2 years), were studied. In addition, 29 patients who received eradication therapy were re-evaluated 2 or 3 months post-treatment. The 13C-labeled urea breath test was positive in 64 patients (35.2%). The sensitivity, specificity and accuracy of the LFI method were 90.6% (95% CI = 80.7–96.5%), 95.8% (92.1–99.4%), and 94.0% (90.5–97.4%), respectively and for the EIA method, sensitivity, specificity and accuracy were 96.8% (95% CI, 89.0–99.6%) and 99.2% (97.5–100%), and 98.3% (96.5–100%), respectively. There were no significant differences in results among the age groups 3–5, 6–10 and 11–17 years. As for the assessment of H. pylori eradication, the results of the LFI and EIA methods agreed with those of 13C-urea breath test in 27/29 and 29/29 patients, respectively. Conclusions. The LFI stool antigen method showed a good sensitivity, specificity and accuracy for diagnosing H. pylori infection in children. This novel method may be useful in clinical practice as an office-based test because it is rapid, reliable and easy to perform.

OBJECTIVES: Although variable-stiffness colonoscopes have been developed, difficult or incomplete colonoscopies occasionally occur. The aim of this study was to evaluate the usefulness of a small-caliber, variable-stiffness colonoscope (scVSC) as a backup in patients with difficult or incomplete colonoscopies. METHODS: First, we retrospectively reviewed the cecal intubation rate of colonoscopies in which an adult standard colonoscope (AC) was immediately switched to an scVSC in all patients in whom a colonoscopy with an AC was incomplete. Second, 374 consecutive patients were randomized to undergo colonoscopy with a pediatric variable-stiffness colonoscope (PVSC, n = 123), AC (n = 125), or scVSC (n = 126). The scVSC was used by the same endoscopist to reattempt colonoscopy immediately after colonoscopy with a PVSC or an AC had been assessed as difficult or incomplete. The cecal intubation rate and time and the ancillary maneuvers used were evaluated. RESULTS: Fifty-two (2.5%) of the 2,056 attempted colonoscopies with an AC did not reach the cecum. Fifty-one of the 52 patients (98.1%) had complete colonoscopies after the switch from the AC to the scVSC. The initial intubation rate and time were not statistically different among the groups: PVSC, 95% and 6.8 min; AC, 91% and 7.5 min; and scVSC, 98% and 8.2 min. Cecal intubation was achieved in all five patients (100%) and in 10 out of 11 (91%) patients, respectively, after the PVSC or AC was switched to the scVSC. CONCLUSIONS: The completion rate markedly improved after switching from an AC or PVSC to an scVSC in difficult or incomplete colonoscopies, although the scVSC does not appear to offer any distinct advantage over the AC or PVSC for routine colonoscopies. (Am J Gastroenterol 2004;99:1936‐1940)

Background. In the Helicobacter pylori-negative normal stomach, collecting venules are visible in the gastric corpus as numerous minute points. This finding has been termed ‘regular arrangement of collecting venules’ (RAC). The aim of the present study was to investigate the reliability of the presence of the RAC pattern for discrimination of normal gastric mucosa from H. pylori gastritis in pediatric patients. Methods. Fifty-two consecutive children, adolescents and young adults (male:female 24 : 28; median age 15 years, range 8–29 years) referred for endoscopy and assessed for H. pylori infection were prospectively studied. The lower lesser curvature of the corpus near the incisura was evaluated for the RAC pattern using a standard endoscope with the tip close to, but not in contact with, the gastric surface. Gastric biopsies were taken after the endoscopic observation. Results. In all the 29 RAC-positive patients, active H. pylori gastritis was absent, whereas H. pylori gastritis was found in 20 of 23 RAC-negative patients (86.9%). Conclusions. Identification of the RAC pattern at the lower lesser curvature of the corpus using close observation with a standard endoscope proved to be an effective and practical marker to discriminate normal histology from H. pylori gastritis among both children and young adults. Absence of the RAC pattern should prompt gastric mucosal biopsies despite otherwise normal-appearing gastric mucosa.

Effective and safe sedation for patients with liver cirrhosis is problematic. To examine the safety and effectiveness of low-dose propofol sedation during and after esophagogastroduodenoscopy (EGD) in cirrhotic patients. Study 1 was a prospective study in cirrhotic patients who underwent diagnostic EGD under propofol sedation. Propofol was given by bolus injection with an age-adjusted standard protocol consisting of 40 mg for patients

AIM: To evaluate the effectiveness of outpatient percutaneous endoscopic gastrostomy (PEG) replacement using esophagogastroduodenoscopy (EGD) and propofol sedation. METHODS: We retrospectively assessed the outcome and complications of consecutive patients referred for PEG replacement which was performed using EGD under propofol sedation in the outpatient setting. The success rate, the mean dose of propofol, procedure time, EGD findings, discharge time from endoscopy unit, respiratory depression, and complications within 72 h of the procedure were evaluated. In a subset of these patients, the blood concentrations of propofol were measured. RESULTS: All 221 patients underwent successful PEG replacement. The mean dose of propofol was 34 mg (range, 20-60 mg) with a mean procedure time of 5.9 min (range, 3-8 min). Reflux esophagitis (12 patients), gastric ulcer (5), gastric neoplasm (2), and duodenal ulcer (1) were newly diagnosed at replacement. Discharge from endoscopy unit was possible in 100% of patients 45 min after the procedure. Only 3.6% (8) required transient supplemental oxygen. No complications occurred within 72 h of the procedure. During EGD the level of sedation and propofol blood concentrations after administration of propofol (30 mg) in these PEG patients corresponded to those of propofol (60 mg) in middle aged subjects (control). CONCLUSION: PEG replacement using EGD and propofol sedationin the outpatient setting was safe and practical.

AIM: To study the safety and effectiveness of propofol sedation for outpatient colonoscopy. METHODS: Propofol was given by bolus injection with an age-adjusted standard protocol consisting of 60 mg for patients < 70 years old, 40 mg for patients age 70-89 years, and 20 mg for those ≥ 90 years, and additional injections of 20 mg propofol were given up to a maximum of 200 mg. The principal parameters were the occurrence of adverse events within 24 h after colonoscopy and overall satisfaction for this procedure. Secondary parameters included successful procedure, respiratory depression, and other complications. RESULTS: Consecutive patients were entered prospectively and all 2101 entered successfully completed outpatient colonoscopy. The mean dose of propofol used was 96.4 mg (range 40-200 mg). Younger patients required higher doses of propofol than older patients (20-40 years vs ≥ 61 years: 115.3 ± 32 mg vs 89.7 ± 21 mg, P < 0.001). Transient supplemental oxygen supply was needed by five patients (0.2%); no other complications occurred. The questionnaires were completed by 1820 (87%) of 2101 patients and most rated their overall satisfaction as excellent (80%) or good (17%). The majority (65%) of patients drove home or to their office after their colonoscopy. Most (99%) were willing to repeat the same procedure. No incidents occurred within 24 h after colonoscopy. CONCLUSION: Propofol sedation using a dose < 200 mg proved both safe and practical for outpatient colonoscopy.

It is commonly recommended that patients refrain from driving for 24 hours after endoscopy for which sedation is given.The aim of this study was to evaluate psychomotor recovery and blood propofol concentrations after colonoscopy with propofol sedation to determine whether driving might be safe.A prospective, consecutive study.Municipal hospital outpatients.This study involved 48 consecutive patients scheduled for colonoscopy with propofol sedation.Patient clinical features, psychomotor recovery, and blood concentrations of propofol were assessed. Psychomotor recovery was assessed before colonoscopy and 1 and 2 hours after colonoscopy by using the number connection test and a driving simulator test.Clinical features, psychomotor recovery, and blood concentration of propofol.All patients successfully completed the post-sedation assessments. Although there was a significant difference in results of the number connection test between before colonoscopy and 1 hour after colonoscopy, all number connection test results were within normal limits (40 seconds). Scores were as follows: mean time (standard deviation) before colonoscopy, 32.2 (2.0) seconds (range 29-36 seconds) versus after colonoscopy, 32.7 (2.0) seconds (range 27-38 seconds); P = .0019. Driving skills had recovered to the baseline levels 1 hour after colonoscopy. Scores were as follows: tracking error (%) before colonoscopy, 45.0 (5.6) versus after colonoscopy, 46.0 (5.5); P = .61; accelerating reaction time in seconds before colonoscopy, 0.65 (0.15) versus after colonoscopy, 0.62 (0.14); P = .40; braking reaction time in seconds before colonoscopy, 0.58 (0.13) versus after colonoscopy, 0.61 (0.13); P = .50.Small sample size, single-center study.Although consistent findings on the number connection test and driving simulation (psychomotor recovery) test are present as early as 1 hour after propofol sedation, a study of additional numbers of patients as well as different patient populations are needed before these results can be universally recommended.

Background: If it is possible, endoscopic decompression for acute left-sided colorectal obstruction will be effective in critically ill patients. This study was to evaluate the techniques and outcomes of transanal drainage tube placement following urgent colonoscopy in management of acute left-sided colorectal obstruction. Methods: From January 2000 to December 2009, 69 consecutive patients (36 males, age 38 to 94, mean = 71) were hospitalized because of acute left-sided colorectal obstruction. Urgent colonoscopy was performed within 12 hours of entry for diagnosis and treatment (mean time, 6.5 hours). Endoscopic decompression using a transanal drainage tube was attempted. Clinical success, methods used, and complications were retrospectively evaluated. Results: The cause of obstruction was colorectal carcinoma in 66 patients (96%). The site of obstruction was sigmoid colon in 37 (54%), rectum in 20 (29%), and descending colon in 12 (17%). Out of 69 patients, endoscopic decompression using the transanal drainage tube was successful in 66 (96%). The use of combination of transanal drainage tube and the equipped guidewire enabled endoscopic decompression was successful in 45 patients (65%), though a small-diameter upper endoscope was used in 2 patients to introduce the guidewire beyond the obstruction. Perforation during the placement developed in 2 patients and one patient was unsuccessful. Conclusions: Transanal drainage tube placement following urgent colonoscopy was effective in the management of acute left-sided colorectal obstruction. In the majority of patients, the materials and methods used for the transanal drainage tube placement were simple and easy. doi:10.4021/gr233w

The original publication is available at www.springerlink.com, Despite the increase in nonalcoholic fatty liver disease (NAFLD) in Japanese adults, its prevalence in adolescents remains unclear. This prompted us to evaluate the incidence and clinical characteristics of NAFLD among junior high school students. A population-based cross-sectional study was conducted among students in a single junior high school in Nagano prefecture. Serum alanine aminotransferase (ALT) and gamma-glutamyltransferase (gamma GT) measurements and abdominal ultrasonography were performed in 249 and 288 students in 2004 and 2007, respectively. In the latter survey, student lifestyle habits were also assessed, using questionnaires. The prevalence of NAFLD was 4.4% and 4.5% in 2004 and 2007, respectively, which was lower than that of obesity (10.0% and 5.9%). Body mass index and ALT and gamma GT levels increased significantly with hepatic steatosis severity. Multivariate logistic regression analysis demonstrated that the presence of obesity and an ALT level of 30 U/L or more were independent predictors of NAFLD (odds ratio 16.9, P < 0.001 and odds ratio 16.6, P = 0.001, respectively). The ratios of students commuting to and from school by car and not doing sports outside of school were higher in NAFLD students compared with non-NAFLD ones. Such tendencies were observed independently of the presence of obesity. Additionally, one obese student with severe steatosis and liver dysfunction was diagnosed as having nonalcoholic steatohepatitis (NASH). Approximately 4% of junior high school students had NAFLD that was primarily associated with obesity and reduced daily physical activity. Serum ALT measurement during school check-ups is recommended for the early detection of young adolescent NAFLD/NASH., Article, JOURNAL OF GASTROENTEROLOGY. 45(6):666-672 (2010)

BACKGROUND Colonoscopy is an excellent but imperfect modality for colorectal cancer screening and prevention. AND AIMS: We studied the effects of a retractable transparent extension device on adenoma detection rate as well as on intubation and withdrawal times. METHODS: Colonoscopy with or without the transparent retractable extension (TRE) was performed by one endoscopist. A subset of patients with colonic adenomas were randomized to repeat colonoscopy with or without a TRE device. Adenoma removal was done at the second colonoscopy. The principal outcome parameters were the cecal intubation time, withdrawal time, and the number, size, and location of adenomas detected. RESULTS: The study was done in two parts. First, 835 patients underwent colonoscopy with or without the TRE. The patients' demographic characteristics, the indications for colonoscopy, the cecal intubation time and withdrawal time, and the proportion of patients with adenomas (29.0% vs 24.1%) (P = 0.11) were similar between the two techniques. The number of adenomas detected with the TRE was significantly higher than that without the extension (205 vs 150) (P = 0.04). Second, 60 patients with adenomas found at colonoscopy without the device were randomized to repeat colonoscopy within 3 months. Hood-assisted colonoscopy revealed 20% more adenomas than the initial procedure compared to a 4% increase without the hood (P = 0.029). CONCLUSIONS: Colonoscopy with a TRE device improved the adenoma detection rate without affecting intubation and withdrawal times.

Background and Aims: Fibroscan (Echosens,France) is a new non invasive tool for measuring liver stiffness and steatosis. It has mainly developed to evaluate chronic liver disease in adult, but usefulness and appropriate inspection method in children has not been established. We report our experience of Fibroscan to evaluate liver stiffness and steatosis in children. Methods: Pediatric patients diagnosed or suspected to have liver disease were evaluated for controlled attenuation parameter (CAP) and elasticity value (E value) using Fibroscan from August 2013 to November 2014. Results: In total, 20 procedures were performed for 19 patients (14 male, average age 11.5 year). CAP was 100 to 348 dB/m, and E value was 3.2 to 21.3 kPa. E values were higher than 10 kPa in three patients, one after receiving liver transplantation, one post Fontan procedure and one Alstrom syndrome. Liver biopsy was performed in four of them (2 Non-alcoholic steatohepatitis:NASH), 1 congenital liver fibrosis, 1 Wilson's disease) at almost the same time and E value was correlated with histological fibrosis stage (F 1-2) in them. CAP and the degree of steatosis in the liver tissue were correlated in NASH patients. After treatment not only the blood data such as transaminase and HOMA-IR but also CAP and E value of the patient of NASH were improved (CAP 323 to 299 dB/m, E value 7.7 to 4.5 kPa). Conclusion: Fibroscan might be useful for evaluating and following up liver stiffness and steatosis of children with liver disease as well as adult.

Background We developed a new method of endoscope holder–assisted percutaneous endoscopic gastrostomy (PEG) placement requiring only a single physician. Objective This study compared the feasibility and safety of the new method with the conventional pull method of PEG performed by 2 physicians. Design Prospective, randomized comparison study. Setting Rural municipal hospital. Patients Eighty consecutive patients with dysphagia. Interventions Patients were randomized to receive PEG placement by a single physician using the endoscope holder (40 patients) or by 2 physicians using the conventional pull method (40 patients). Main Outcome Measurements The success rate, duration, and complications of both methods were scored. Results The success rate of PEG by either method was similar (98%) using the endoscope holder compared with 100% with the conventional method. The duration of both endoscopic procedures was also similar (12.9 ± 2 and 11.5 ± 2 minutes) ( P = .43). No major complication occurred with either procedure. There was 1 death within 30 days (of aspiration pneumonia) 3 days after conventional PEG placement. Limitations The number of patients evaluated is small. Conclusions Endoscope holder–assisted PEG placement allows a single physician to perform all the important aspects of pull PEG placement under direct vision without assistance from another specially trained individual. The method appears to be as feasible and safe as the conventional pull method.

This study was designed to assess the acceptability and the diagnostic accuracy of unsedated ultrathin EGD (uUT-EGD) by using a newly developed 5.2-mm-diameter videoscope compared with unsedated small-caliber EGD (uSC-EGD) by using a 6.5-mm-diameter videoscope or sedated conventional EGD (sC-EGD) by using a 9.0-mm-diameter videoscope.First, 80 patients who had undergone uSC-EGD approximately 1 year earlier were randomized to receive uUT-EGD (n = 40) or uSC-EGD (n = 40). Endoscopist satisfaction and patient comfort were assessed by using a 10-cm visual analog scale. Patient comfort level was compared with that of the previous uSC-EGD. Second, 40 patients who had undergone sC-EGD within the previous 1.5 years underwent uUT-EGD. The optical quality and EGD findings of uUT-EGD were compared with those of the previous sC-EGD. Last, in the 80 patients undergoing uUT-EGD, the ability to identify a validated endoscopic marker, the rearrangement of collecting venues (RAC) pattern, for no Helicobacter pylori, was compared with the results of a (13)C-urea breath test or H pylori stool antigen test.Showa Inan General Hospital, Komagane, Japan.A total of 120 patients who undergo EGD every year as part of a gastric cancer surveillance program.The patient comfort level of uUT-EGD was significantly better than that of uSC-EGD (P.0001). The optical quality of the endoscopic images and the EGD findings of uUT-EGD were similar to those of the previous sC-EGD. The overall sensitivity, specificity, and accuracy of the RAC pattern in uUT-EGD in recognizing H pylori-uninfected patients were 90%, 100%, and 93%, respectively. The interobserver agreement for RAC was good (kappa = 0.42).The use of a 5.2-mm-diameter videoscope is expected to enhance the patient acceptance of unsedated EGD.

Background: The life expectancy of the population is rising. The number of octogenarian (80 years or older) undergoing endoscopy evaluation is rising. The utility of double balloon enteroscopy (DBE) procedure in Octogenarians have not been previously reported. Aim: To determine the safety and diagnostic yield of DBE procedure in the octogenarians. Methods: We reviewed our large prospectively collected DBE database from 2006 to 2011. The octogenarian patients aged 80 years or older were included in our study analysis. Patients' demographics along with DBE procedure indication, findings, and complications were recorded. The safety and diagnostic yield of DBE procedure was calculated by the frequency statistics. Results: A total of 1218 DBE procedure were performed from 2006 to 2011 at our tertiary referral center. Out of these DBE procedures, 108 DBE (60 antegrade and 48 retrograde approaches) performed in 86 different patient encounters among 68 octogenarian (54.4% Male) were included in our study analysis. The average age of these patients was 84 (80-95) years and BMI was 26.2 (18.6-45.13) kg/m2. The most common indication for DBE was overt bleeding 29.6% (See table below). The most common finding during these DBE was bleeding AVM (arterio-venous malformation) among 38% (n=33) encounters. The overall diagnostic (pertinent positive findings) or therapeutic yield of DBE was found to be 91.86% (79/86 encounters). The diagnostic and therapeutic yield was found to be 91% (71/ 78 encounters) for evaluation of gastrointestinal bleeding and 100% (5/5 encounters) for evaluation of suspected mass or bowel stricture among octogenarian. There was no immediate (

Background and Aims: The epidemiology of gastrointestinal disorder is poorly described among Japanese children. Our aim is to clarify the trend of GI diseases' prevalence at Pediatric GI practice in Japan over the last decade. Methods: Children and adolescents with GI symptoms from 2001 to 2011 were identified by endoscopic databases at Shinshu University Hospital and Showa Inan General Hospital. Procedures were performed by pediatric GIs and routine biopsies were taken from every landmark. The prevalence of newly diagnosed GI disorders, especially Helicobacter pylori related disorders, eosinophilic gastrointestinal diseases (EGIDs) and inflammatory bowel disorder (IBD), are evaluated. Results: In total, 772 procedures (534 esophagogastroduodenoscopy[EGD] and 237 colonoscopy[CS]) were performed for 552 Japanese children and adolescents (54% female, average 11.47±4.57 year). Of 552 patients, 93 (18%) had H. pylori infection, and 27 (29%) of H. pylori positive subjects had peptic ulcer (22 duodenal ulcer and 5 gastric ulcer). Twenty-two patients (4%) were diagnosed as EGIDs (11 eosinophilic gastroenteritis, 11 eosinophilic colitis and no patient of eosinophilic esophagitis despite routine biopsies from esophagus). Twelve patients were diagnosed as IBD (10 Ulcerative colitis and 2 Crohn's disease). The trend of each disorder was shown in Figure 1. Conclusion: EGIDs have increased dramatically in a few years. On the other hand, H. pyori infection decreased almost one-fifth over 10 years in Japanese children.

Comparison of Nurse Administered Propofol and Midazolam for Endoscopic Procedures in Very Elderly Or High-Risk Patients Akira Horiuchi, Yoshiko Nakayama Objectives: Propofol is a sedative agent that is superior to benzodiazepines with regard to rapid induction of sedation and faster recovery. However the possibility of serious adverse effects such as respiratory and cardiovascular depression have made many endoscopists reluctant to use propofol. We compared nurse-administered propofol to midazolam for sedation in very elderly (O85) or high-risk patients with chronic pulmonary disease (PaO2 ! 55 torr at rest) undergoing endoscopic procedures. Methods: During a 12-month period, 40 very elderly (O85) or high-risk patients were randomized to receive propofol or midazolam for sedation undergoing percutaneous endoscopic gastrostomy. After initial intravenous administration of 20 mg propofol, the dose was titrated in increments of 10 mg against clinical response. Midazolam was administered at a single set dose of 4 mg. The mean dose of each drug, procedure time, recovery time, and complications were evaluated. The blood levels of the drugs were measured before and at 30, 60, 120, and 180 after the injection of each drug. Results: The mean doses of propofol and midazolam administered were 35 mg (range, 20-40 mg) and 4 mg, respectively. Procedure times and the level of sedation achieved between the groups were similar: propofol 15 C 1.9 min; midazolam, 14 C 2.1 min) (p Z 0.22). Time to full recovery was faster in the propofol group: 44.9 C 11 min vs. 123 C 23 min) (p ! 0.001). No major complications occurred in either group. There was, however, an increased risk for a short oxygen desaturation (!90%) with midazolam (5.6%) compared to 1.7% with propofol in the very elderly group (p Z 0.036). Neither had a pronounced influence on arterial pressure or heart rate. Propofol concentrations ranged from 34 to 96 ng/ml (mean 55 ng/ml) 60 min post injection whereas midazolam ranged from 0.12 to 1.6 mg/L (mean 0.55 mg/L) at 180 min. Conclusions: There was faster recovery and a lower incidence of respiratory depression with propofol than with midazolam in very elderly or highrisk patients undergoing endoscopy. Nurse-administered propofol is a safe and reasonable sedation method for endoscopy in very elderly (O85) or high-risk patients.

To the editor: Unsedated esophagogastroduodenoscopy (EGD) is a routinely performed diagnostic procedure in Japan. However, because unsedated EGD with large-diameter endoscopes causes most patients much discomfort and anxiety, it has acquired a negative image and has lead people to avoid it, even when EGD is medically indicated. More recently, a 6.5-mm diameter endoscope has been produced in Japan to allow tolerable, technically feasible, and efficient EGD without the need for sedation. Its capabilities are designed to be equal to those of the standard endoscope; its outer diameter is considered larger than those of the previous small-diameter endoscopes (1, 2, 3). When an endoscopist swallowed the 6.5-mm diameter endoscope to perform EGD on himself and assess the acceptability, feasibility, and imaging quality of the device for unsedated EGD, he happened to find erosion in his duodenal bulb (Fig. 1).