White spots around colorectal tumors are cancer-related findings and may aid endoscopic diagnosis: a prospective study in Japan.

Background/Aims: During endoscopy, white spots (WS) are sometimes observed around benign or malignant colorectal tumors; however, few reports have investigated WS, and their significance remains unknown. Therefore, we investigated the significance of WS from clinical and pathological viewpoints and evaluated its usefulness in endoscopic diagnosis. Methods: Clinical data of patients with lesions diagnosed as epithelial tumors from January 1, 2019, to December 31, 2020, were analyzed (n=3,869). We also performed a clinicopathological analysis of adenomas or carcinomas treated with endoscopic resection (n=759). Subsequently, detailed pathological observations of the WS were performed. Results: The positivity rates for WS were 9.3% (3,869 lesions including advanced cancer and non-adenoma/carcinoma) and 25% (759 lesions limited to adenoma and early carcinoma). Analysis of 759 lesions showed that the WS-positive lesion group had a higher proportion of cancer cases and larger tumor diameters than the WS-negative group. Multiple logistic analysis revealed the following three statistically significant risk factors for carcinogenesis: positive WS, flat lesions, and tumor diameter ≥5 mm. Pathological analysis revealed that WS were macrophages that phagocytosed fat and mucus and were white primarily because of fat. Conclusions: WS are cancer-related findings and can become a new criterion for endoscopic resection in the future.

Endoscopic sealing hemostasis with polyglycolic acid sheet and fibrin glue as a novel endoscopic hemostatic technique: a report of three cases.

Polyglycolic acid sheets and fibrin glue are routinely used in surgical procedures. Their usefulness in gastrointestinal endoscopy is mainly to prevent complications (bleeding, delayed perforation, stenosis, etc.) associated with procedures such as endoscopic submucosal dissection and endoscopic mucosal resection, with most reports on iatrogenic and secondary conditions. However, there are few reports on primary gastrointestinal diseases. Herein, we report three cases of gastrointestinal bleeding that were successfully treated with endoscopic hemostasis by sealing the lesions with polyglycolic acid sheets and fibrin glue. Case 1 was of an 83-year-old woman with a rare duodenal perforation that was treated with omental plugging who experienced subsequent bleeding from the greater omentum. Case 2 was of a 73-year-old woman with an acute hemorrhagic rectal ulcer that was difficult to treat even after performing standard endoscopic hemostasis techniques; however, surgery was avoided by sealing. Case 3 was that of an 89-year-old woman with a stercoral ulcer, treated curatively using a combination of sealing and argon plasma coagulation right from presentation based on the lessons learned from Cases 1 and 2. Endoscopic hemostasis using a polyglycolic acid sheet and fibrin glue may be a new treatment option for gastrointestinal bleeding particularly in refractory or rare causes.

Small bowel cancer in a patient with Crohn's disease diagnosed preoperatively by double-balloon enteroscopy.

A 53-year-old female patient, who had been treated for Crohn's disease for approximately 20 years, was admitted to our hospital with a chief complaint of persistent bloody stools. Colonoscopy, computed tomography, and magnetic resonance enterography revealed two stenoses of the ileum and multiple enlarged lymph nodes around the oral-side ileal stenosis. We accordingly performed transoral double-balloon enteroscopy and found ileal stenosis with an irregular mucosal surface. Based on pathological examination of the stenosis, adenocarcinoma of the small bowel was diagnosed for the oral-side stenosis. The stenosis on the anal side was benign. The two stenoses were resected simultaneously, and lymph node dissection was performed on the cancerous lesion. The diagnosis of the cancerous lesion was pStage IIIB, and immunohistochemical staining was positive for tumor protein 53. Patients with Crohn's disease are at a high risk of small bowel cancer, but no surveillance protocol has been established to date. We encountered a case of Crohn's disease in which radical surgery was possible, owing to preoperative pathological diagnosis, by using balloon-assisted enteroscopy. In this paper, we report a case that suggests the importance of performing balloon-assisted enteroscopy when small bowel stenosis is detected in patients with Crohn's disease.

Intestinal Obstruction Due to Reassembly after Endoscopic Crushing of a Bezoar.

An 87-year-old woman visited her primary-care doctor because of nausea and epigastric pain. Esophagogastroduodenoscopy (EGD) revealed a giant bezoar in her stomach. She was referred to our hospital after carbonated beverage dissolution proved ineffective and underwent endoscopic mechanical crushing. After crushing, the symptoms disappeared, and she began eating. Later, however, the crushed fragments reassembled in the duodenal bulb and caused intestinal obstruction. The patient underwent emergency EGD for crushing once more, and all of the fragments were extracted from the body. This case highlights the need for bezoars to be removed from the body after crushing in order to avoid reassembly.

Microsatellite Instability-high-positive Cancer of Unknown Primary Origin with a Long-term Survival after Surgery Alone.

An 80-year-old woman was referred to our hospital for a thorough examination of enlarged lymph nodes on the lesser curvature of the stomach. Upon suspicion of malignant lymphoma, the patient underwent open lymphadenectomy and was diagnosed with lymph node metastasis of poorly differentiated adenocarcinoma. The patient was subsequently diagnosed with microsatellite instability-high cancer of unknown primary origin. Surgical removal of the affected lymph nodes achieved full remission. Chemotherapy was considered in case of recurrence or identification of the primary site. Recurrence has not occurred in three years since the surgery. However, a long-term survival without chemotherapy is rare.

Gastric Arteriovenous Malformation with Characteristic Endoscopic Findings.

Gastric arteriovenous malformation (AVM) is an uncommon cause of upper gastrointestinal bleeding, and the endoscopic findings are unclear. We herein describe a case of gastric AVM in a 28-year-old man. Esophagogastroduodenoscopy showed a Dieulafoy lesion surrounded by a red mucosa with a sharp margin, which implied blood vessel malformation. Computed tomography angiography and conventional angiography revealed aggregated vessels on the greater curvature. Partial gastrectomy was performed, with no recurrent bleeding postoperatively. The histopathological diagnosis was AVM. We conclude that gastric AVM should be considered in the differential diagnosis of patients who present with a Dieulafoy lesion surrounded by a red mucosa.