Jun Takada

Background/Objectives: Oral prednisolone (PSL) and budesonide multi-matrix (BUD-MMX) are used to induce remission in ulcerative colitis (UC); however, their therapeutic positioning remains unclear. Comparative data from real-world practices are limited. This study assessed the efficacy and safety of PSL and BUD-MMX in patients with active UC. Methods: Consecutive outpatients with UC initiated on oral PSL or BUD-MMX at two tertiary referral centers were included. The primary outcome was clinical remission at week 8, defined as a partial Mayo score (PMS) ≤ 1 with a rectal bleeding subscore of 0. Secondary outcomes included clinical response and safety. Pre-specified subgroup analyses were performed according to baseline disease activity. Results: Sixty PSL-treated and 40 BUD-MMX-treated patients were evaluated at week 8. Clinical remission was achieved in 65.0% and 55.0% of the PSL and BUD-MMX groups, respectively, whereas a clinical response was observed in 75.0% and 62.5%, respectively. No patient with a baseline PMS of 2–3 was initiated on PSL. Among patients with a baseline PMS of 4–5, the remission and response rates at week 8 were similar between the groups. In contrast, remission in patients with a baseline PMS ≥ 6 was numerically lower in the BUD-MMX group. Treatment escalation rates were comparable in the overall cohort, whereas adverse events were more frequent in the PSL group (23.3% vs. 2.4%). Conclusions: Treatment selection between PSL and BUD-MMX appeared to reflect baseline disease activity, with a partial overlap in the moderate clinical range. BUD-MMX may be a reasonable initial option for selected patients.

Colonic metastasis from dermatofibrosarcoma protuberans (DFSP) is exceedingly rare, and few reports have described its characteristic endoscopic features. Here, we report the case of a 66 year-old woman with a history of DFSP who presented with a colonic lesion detected during colonoscopy. The lesion appeared as a firm, subpedunculated, elevated mass in the descending colon. At the initial examination, the lesion was covered with intact epithelium; however, at a follow-up examination 6 weeks later, the surface epithelium had sloughed off. Endoscopic ultrasonography revealed a predominantly submucosal nodule. Endoscopic mucosal resection yielded sufficient tissue to establish a definitive diagnosis of metastatic DFSP. This case highlights not only the exceptional rarity of colonic metastasis from DFSP but also the diagnostic value of careful endoscopic evaluation—including the observation of dynamic changes in lesion morphology—as well as the role of endoscopic resection in obtaining adequate diagnostic tissue.

Objectives: Few attempts have been made to determine the risk factors for the recurrence of esophageal varices (EV) and the optimal surveillance interval. This study analyzed whether endoscopic ultrasonography can be used to predict EV recurrence and determine the optimal timing for surveillance endoscopy post‐treatment. Methods: We retrospectively evaluated patients with EVs who underwent endoscopic variceal ligation (EVL) combined with argon plasma coagulation (APC), followed by endoscopic ultrasonography (EUS) using a miniature ultrasonic probe 1 month after APC. Factors associated with EV recurrence were assessed using the Fine‐Gray competing risk regression model, with death considered as the competing risk. The cumulative incidence of EV recurrence was estimated using the cumulative incidence function, and groups were compared using Gray's test. Results: Of 163 eligible patients, 37 (23%) experienced EV recurrence during a median follow‐up period of 36 months (interquartile range: 15–76 months). Multivariable analysis revealed that the presence of perforating veins (PVs) was a significant factor for EV recurrence (sub‐distribution hazard ratio, 4.30; 95% confidence interval, 2.13–8.71; p < 0.001). The cumulative incidence of EV recurrence was significantly higher in patients with PV than in those without (6‐month and 1‐year recurrence rates: 27.3% and 41.6% vs. 3.9% and 5.5%, respectively; p < 0.001). Conclusions: PVs detected using EUS independently predict EV recurrence risk after EVL combined with APC. Given that patients with PVs experience a high recurrence rate within 6 months, comprehensive surveillance endoscopy at 6‐month intervals is recommended in the first year post‐treatment.

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An 86-year-old man presented to our hospital with symptoms of diarrhea and bloody stool, which had manifested two weeks after receiving his third SARS-CoV-2 mRNA vaccination. Colonoscopy revealed diffuse, rough-surfaced mucosa extending from the ascending colon to the rectum. Despite attempting probiotic treatment, the patient's condition did not improve, leading to admission. Endoscopic findings at admission worsened. Based on endoscopic and histopathological findings, the patient was diagnosed with ulcerative colitis. Corticosteroids and 5-aminosalicylic acid were administered, and the clinical symptoms improved. Subsequently, the disease worsened during steroid tapering, and filgotinib was added, leading to steroid-free remission.

Background: Cecal intubation during colonoscopy is difficult to achieve in patients with severe sigmoid adhesions. This retrospective observational study assessed the efficacy of using a gastroscope for colonoscopy in patients with severe sigmoid adhesions. Furthermore, the ability of computed tomography (CT) to predict the possibility of cecal intubation using a gastroscope was examined. Methods: A total of 1,626 patients who underwent colonoscopy for total colon observation by one endoscopist were enrolled. Cecal intubation rate and other procedure-related outcomes were evaluated. We also investigated whether identification of the sigmoid colon pathway by CT was involved in cecal intubation rate using a gastroscope. Results: Of the enrolled patients, cecal intubation by colonoscope was not feasible in 19 patients (1.2%) because of severe sigmoid adhesions. Cecal intubation was possible in 13 patients (68.4%) using a gastroscope, and the cecal intubation rate of peritoneal carcinomatosis (0%, p < 0.01) was significantly lower than that of other causes such as a diverticulum (100%) and history of gynecologic surgery (80%). The identifiable case of the sigmoid colon pathway by horizontal section on CT showed significantly higher cecal intubation rate compared to those of unidentifiable cases (92.3% vs. 16.7%, p < 0.01). Conclusion: Using a gastroscope is effective in performing cecal intubation during colonoscopy in patients with severe sigmoid adhesions. However, in patients with sigmoid adhesions caused by peritoneal carcinomatosis, cecal intubation may be difficult, even when a gastroscope is used. The ability of CT to identify the sigmoid colon pathway may predict success of cecal intubation.

Extensive mucosal resection by esophageal endoscopic submucosal dissection (ESD) can lead to strictures [1]. Oral or locoregional steroid injections are used to prevent stenosis, but they are not effective in all cases [2] [3]. Endoscopic balloon dilation is the primary option for treating post-ESD strictures [4]; however, its applicability in previously perforated areas is challenging because of the risk of reperforation. Herein, we present a valuable case of radial incision and cutting for managing a post-ESD esophageal stricture with a prior perforation during endoscopic balloon dilation. A 76-year-old man with widespread superficial esophageal squamous cell carcinoma underwent ESD, with resection extending over 80% of the esophagus. Despite locoregional steroid injection, a stricture developed. A perforation occurred during endoscopic balloon dilation for stricture management ([Fig. 1]). Following clip closure and fastening, the perforation healed, but restenosis ensued. Considering the risk of re-perforation, endoscopic balloon dilation was deemed unsuitable; therefore, we decided to perform radial incision and cutting to avoid surgical intervention. The previous perforation site was at the 4 oʼclock position near the mouth side edge ([Fig. 2]); therefore, the incision was made from different directions using an electrosurgical knife (Dual-Knife J, KD-655Q; Olympus Optical Co., Tokyo, Japan). A cut was carefully made to avoid exposing the muscle layer. A fibrous tissue was removed and the lumen was enlarged until the anal edge of the stricture could be observed, allowing visualization of the direction for safe incision. The incision was advanced in a safe direction viewed from the anal side edge of the stricture to further enlarge the lumen. Finally, the stricture was sufficiently dilated to facilitate easy passage of the scope ([Fig. 3], [Video 1]). Additional oral and locoregional steroid injections were administered. After 2 months, a scarred radial incision and cutting region without restenosis was observed ([Fig. 4]). Endoscopy_UCTN_Code_TTT_1AO_2AH Article published online: 11 December 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Colonic diverticular bleeding is the most common cause of bleeding in the lower gastrointestinal tract [1]. Endoscopic identification of stigmata of recent hemorrhage (SRH), such as active bleeding, adherent clot, or visible vessel, is important but often difficult [2] [3]. The waterjet scope, the use of which has been reported to be an independent predictive factor for identifying SRH, is primarily used to wash away feces or clots inside the diverticulum [4]. Herein, we describe a useful case of water pressure observation for the detection of SRH and endoscopic direct clipping of diverticular bleeding. A 75-year-old man with hematochezia had undergone repeated colonoscopies. Multiple diverticula were observed in the right colon, but spontaneous hemostasis prevented the identification of bleeding points. Therefore, the patient was transferred to our hospital. He developed hematochezia again 2 days later. We performed an urgent colonoscopy with bowel preparation. We used a colonoscope with waterjet function (PCF-H290TI; Olympus Medical Systems, Tokyo, Japan). We attached a super-soft transparent hood without slits (Space adjuster; TOP, Tokyo, Japan). Fresh blood and multiple diverticula with hemostatic clips applied by a previous physician were observed in the right colon; however, the bleeding stopped spontaneously ([Fig. 1 a]). We placed the tip hood of the scope in close contact with each diverticulum and inflated it with water. The water pressure opened the diverticulum, which facilitated observation of the interior. We detected a pulsating visible vessel within a diverticulum in the ascending colon ([Fig. 1 b]). Although the diverticulum could not be inverted, we inflated it with water to create a working space that allowed direct pinpoint clipping with a short-armed hemostatic clip (HX-610-135XS; Olympus) ([Fig. 2], [Video 1]). Video 1 Water pressure observation for detection and direct clipping of source of colonic diverticular bleeding. The patient was discharged without additional intervention. The patient had no rebleeding during the 2-month follow-up period. Endoscopy_UCTN_Code_TTT_1AQ_2AZ Article published online: 26 May 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany