<b><i>Background:</i></b> In both Western countries and in Japan, the incidence of colonic diverticular bleeding has increased with increased use of antithrombotic and nonsteroidal anti-inflammatory drugs (NSAIDs). Therefore, the Japan Gastroenterological Association issued guidelines for colonic diverticular bleeding and colonic diverticulitis in Japanese in 2017 and in English in 2019. However, the guidelines contain unresolved problems. Herein, we review the recent treatment trends for colonic diverticular bleeding in Japan. <b><i>Summary:</i></b> Colonic diverticular bleeding necessitates frequent blood transfusions due to rebleeding, and patients require prolonged hospitalization. Endoscopic treatment plays an important role in treating diverticular bleeding. Currently, endoscopic band ligation (EBL) and endoscopic clipping are used in Japan for diverticular hemorrhage when the source of the hemorrhage is identified. EBL results in significantly lower early (&#x3c;30 days) and 1-year rebleeding rates and long-term recurrence rates compared with endoscopic clipping. Furthermore, the proportion of patients requiring transcatheter arterial embolization or surgery after EBL is significantly lower than that following endoscopic clipping. Several reports state that EBL is superior to endoscopic clipping; however, EBL has associated complications, and it is necessary to carefully consider the individual patient. <b><i>Key Messages:</i></b> EBL is superior to endoscopic clipping regarding short- and long-term rebleeding rates and the rate of transition to surgery and embolization. Methods for preventing diverticular hemorrhage have not been established, but NSAIDs should be discontinued if possible. Prevention strategies for diverticular bleeding need to be evaluated in studies with large sample sizes.

Background: Endoscopic retrograde pancreatography (ERCP) is sometimes complicated by post-ERCP pancreatitis (PEP), which is a severe adverse effect. Objective: The present study was performed to (i) evaluate the risk factors for PEP and (ii) compare the risk of PEP after ERCP performed in the off hours versus regular hours. Methods: This retrospective study included 374 patients who underwent ERCP from January 2013 to December 2017. Among these patients, 38 (10.2%) developed PEP. The potential risk factors for PEP were evaluated by multivariate regression analysis, and the risk of PEP was compared between ERCP performed during regular hours and off hours. Results: The independent risk factors for PEP were a relatively younger age (< 75 years; p = 0.024), female sex (p = 0.002), a history of pancreatitis (p = 0.044), and performance of pancreatography (p = 0.010). Use of a diclofenac suppository and performance of pancreatic stenting were not preventive for PEP after ERCP. The complication rate of PEP did not differ between ERCP performed during the off hours versus regular hours. Conclusions: A relatively younger age (< 75 years), female sex, a history of pancreatitis, and performance of pancreatography were potential risk factors for PEP, whereas the risk of PEP was not different between ERCP performed during the off hours versus regular hours.

<b><i>Introduction/Aims:</i></b> Immune checkpoint inhibitors (ICIs) sometimes cause immune-related adverse events (irAEs), of which there is little information in the literatures. The objective of this study was to characterize the clinical features of gastrointestinal irAEs (GI irAEs). <b><i>Materials and Methods:</i></b> From a total of 250 patients who were administered anti-PD-1 antibodies (nivolumab and pembrolizumab), we retrospectively identified 9 patients with grade 2 or higher GI irAE based on medical records. Patient characteristics, clinical features, imaging and pathological findings, and treatment course were evaluated. <b><i>Results:</i></b> Grade 2 or higher GI irAEs were observed in 9 (3.6%) patients. Of the 9 patients who experienced GI irAE, 8 were male, and mean age was 63.2 years. Five patients received nivolumab and 4 received pembrolizumab. The GI irAEs observed were diarrhea in 7 patients and bloody stool in 2 patients. Grade 2 GI irAEs were identified in 3 patients and grade 3 GI irAEs in 6 patients. The average time from ICI administration to the onset of GI irAEs was 22.2 weeks (range 7–56 weeks) for nivolumab and 19.7 weeks (range 11–28 weeks) for pembrolizumab. Endoscopic findings showed ulcerative colitis-like findings in 3 of 7 patients, and pathological examination revealed crypt epithelial cell apoptosis in 6 of 7 patients. Eight of the 9 patients received steroids, and 2 patients received infliximab additionally. All GI irAEs were manageable. <b><i>Conclusions:</i></b> Because of the lack of specific clinical, imaging, and pathological findings, information of ICI use was indispensable for diagnosis. Although GI irAEs are controllable by steroid and infliximab, further studies regarding management strategy will be needed.

A 76-year-old woman with skin rashes was diagnosed with dermatomyositis in dermatology. Malignancy screening showed right breast cancer with axillary lymph node metastasis on computed tomography. The histopathology of breast cancer was invasive lobular carcinoma. A white, flat, elevated lesion 10 mm in size was identified at the descending colon in screening colonoscopy (Figure A). Dilated crypts can be seen in magnifying endoscopy (Figure B). Endoscopic mucosal resection was performed because a sessile serrated adenoma/polyp could not be excluded. Histopathologic examination showed the infiltration of tumor cells with eosinophilic cytoplasm in the lamina propria (Figure C). Immunohistochemical analysis indicated that tumor cells were positive for gross cystic disease fluid protein-15 (Figure D) and mammaglobin. The lesion was diagnosed as a colon metastasis of breast cancer. As a result, tumor staging was stage IV, and the patient is receiving chemotherapy. Previous reports have shown that the most common sites of metastases of breast cancer are bone, lung, liver, and brain, and gastrointestinal metastasis, especially in the colon, is very rare. The incidence of gastrointestinal metastasis of breast cancer is approximately 1% and the estimated metastatic rate to the colon is 0.1%. Nonspecific symptoms and various appearances of metastatic lesions may confuse the diagnosis. Conflicts of interest The authors disclose no conflicts.

Background/Aims: Proton pump inhibitors (PPIs) are widely used for the management of acid-related diseases. This study aimed to clarify the status of PPI use in hospitalized patients. Method: A retrospective observational study was performed. We analyzed PPI prescription data for the past 8 years (2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016) using Diagnosis Procedure Combination survey data from approximately 10,000 patients per year at Saga University Hospital. We investigated the trend in the number of hospitalized patients who were prescribed PPI for the past 8 years and the changes in patient characteristics. Results: We identified 11,009 patients using PPIs throughout the study period. PPI prescription proportions significantly increased over the study period. The use of PPIs increased steadily with increasing age. The proportion of PPIs prescribed was 1.3-times higher among men than compared with women. In most clinical departments, the num-ber of patients prescribed PPIs was up to 3 times higher in the second half of the period (2013-2016) compared with the first half of the period (2009)(2010)(2011)(2012). The number of patients taking concomitant PPIs and anticoagulants or dual antithrombotic combination therapy increased. Conclusion: PPI use has increased substantially in hospitalized patients. The prevalence of PPI prescription by doctors other than gastroenterologists also increased.