We report the case of a patient with Crohn's disease who initially presented with a ceco-urachal fistula. The patient was a 31-year-old female who underwent an appendectomy 6 years before presenting to our institution. She had a one-year history of diarrhea, and had recently developed polyuria and a sensation of residual urine. She was admitted with fever and lower abdominal pain. Endoscopy and computed tomography revealed a ceco-urachal fistula, which was consistent with Crohn's disease. An urachal resection was performed, which included partial cystectomy and ileocecal resection. A ceco-urachal fistula is a rare initial symptom of Crohn's disease. During the surgical management of such cases, it is necessary to resect the urachus, the affected portion of the bladder, the fistula, and the affected part of the digestive tract in order to avoid recurrence.

We describe a patient with Crohn's disease (CD) concurrent with systemic lupus erythematosus (SLE). Continuous prednisolone and cyclosporine treatment resulted in no recurrent symptoms. However, diarrhea, vomiting, and fever occurred for approximately 3 months. A colonoscopy was then performed, which showed a discontinuous cobblestone appearance and longitudinal ulcers extending from the sigmoid colon to the descending colon and distal ileum. A biopsy revealed a noncaseating granulomatous lesion in the colonic mucosa. These findings led to a diagnosis of CD concurrent with SLE. We first attempted treatment with a full elemental diet, mesalazine, and azathioprine, in that order. However, as there was no improvement in inflammation, we started infliximab, a tumor necrosis factor-alpha inhibitor. Transanal double-balloon enteroscopy performed 4 months after starting infliximab showed mucosal healing, suggesting that infliximab was effective. There are few reports of treating patients with CD concurrent with SLE using a tumor necrosis factor-alpha inhibitor. We report our experience with a patient who had mucosal healing with infliximab and review the literature.

The pink color sign in iodine unstained areas is useful to differentiate esophageal squamous cell carcinoma (ESCC) from other lesions. However, some ESCCs have obscure color findings which affect the ability of endoscopists to differentiate these lesions and determine the resection line. Using white light imaging (WLI), linked color imaging (LCI) and blue laser imaging (BLI), 40 early ESCCs were retrospectively evaluated using images before and after iodine staining. Visibility scores for ESCC by expert and non-expert endoscopists were compared using these three modalities and color differences measured for malignant lesions and surrounding mucosa. BLI had the highest score and color difference without iodine staining. Each determination with iodine was much higher than without iodine regardless of the modality.With iodine, ESCC mainly appeared pink, purple and green using WLI, LCI and BLI, respectively and visibility scores determined by non-experts and experts were significantly higher for LCI (both p < 0.001) and BLI (p = 0.018 and p < 0.001) than for WLI. The score with LCI was significantly higher than with BLI among non-experts (p = 0.035). With iodine, the color difference using LCI was twice that with WLI and one with BLI was significantly larger than with WLI (p < 0.001).These greater tendencies were found regardless of location, depth of cancer or intensity of pink color using WLI. In conclusion, areas of ESCC unstained by iodine were easily recognized using LCI and BLI. Visibility of these lesions is excellent even by non-expert endoscopists, suggesting that this method is useful to diagnose ESCC and determine the resection line.

Background and aimsThe standard treatment for stage T1b colorectal cancers with 1,000µm or greater submucosal invasion is surgical resection. However, the risk of lymph node metastases is only 1-2% when excluding risk factors for metastases other than depth of submucosal invasion. The number of elderly patients with significant comorbidities is increasing with societal aging in Japan. Therefore, local endoscopic resection of T1b colorectal cancers needs more consideration in the future. We previously showed that the pocket-creation method (PCM) for endoscopic submucosal dissection (ESD) is useful regardless of the morphology, including large sessile tumors with submucosal fibrosis, or location of the colorectal tumor. However, some T1b colorectal cancers have pathologically positive margins even when using the PCM. We retrospectively investigated the causes of failure to achieve negative vertical margins.MethodsWe retrospectively analyzed 953 colorectal tumors in 886 patients resected with the PCM. Finally, 65 pathological T1b colorectal cancers after en bloc resection were included in this study. ESD specimens and recorded procedure videos of T1b cancer resections with pathologically positive vertical margins were reviewed.ResultsThe 65 cancers were divided into positive vertical margin (VM+ group) and negative vertical margin (VM- group) groups with 10 [10/65 (15%)] and 55 [55/65 (85%)] patients in each group, respectively. There was a significant difference in the rate of submucosal fibrosis (P=0.012) and dissection speed (P=0.044). There were no significant differences between the two groups in other regards. When verifying 8/10 available videos in the VM+ group, endoscopic technical factors led to positive vertical margins in five patients, and essential pathological factors of ESD led to positive vertical margins in the other three. Six of these eight patients underwent additional surgical resection. No residual tumor was identified in six T1b cancers. None of these six resected specimens contained lymph node metastases on pathological examination.ConclusionThe PCM resulted in a high rate of negative-vertical-margin resections. The PCM resulted in complete resection of T1b cancers when examining additional surgical specimens. ESD using the PCM is a viable option for the endoscopic treatment of T1b colorectal cancers.