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Small-bowel submucosal tumors (SMTs), such as GI stromal tumors, are difficult to diagnose before surgical treatment. If the SMT is diagnosed as a benign tumor before treatment, it can be followed-up without surgery. An SMT 13 mm in diameter was found in a 61-year-old man in the middle jejunum during a double-balloon endoscopy (DBE) performed to explore the cause of enteritis. The enteritis was cured by conservative therapy, but the SMT remained at the follow-up DBE 10 months later. EUS during DBE revealed that a heterogeneous hypoechoic mass originated from the third layer, including the anechoic portion. An ectopic pancreas was suspected but not definitively diagnosed. To more accurately diagnose the SMT, a partial EMR was performed at the time of the DBE. A post-EMR ulcer was closed by using hemoclips (Fig. 1) (Video 1, available online at www.giejournal.org). No adverse events were observed. Histopathologic examination revealed excretory ducts. The SMT was diagnosed as ectopic pancreas, based on EUS and histopathologic findings, and it was decided that the lesion should be followed without surgery. The partial EMR technique is useful for the management of patients with an undiagnosed SMT in the small bowel, although it presents a risk of bleeding. DISCLOSURE

This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. Arihiro Nakano, MD, Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Yoshiki Hirooka, MD, PhD, Department of Endoscopy, Nagoya University Hospital, Osamu Watanabe, MD, PhD, Masanao Nakamura, MD, PhD, Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Takeshi Yamamura, MD, PhD, Department of Endoscopy, Nagoya University Hospital, Takafumi Ando, MD, PhD, Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Hidemi Goto, Prof, Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan

http://dx.doi.org/10.1016/j.gie.2014.08.011

All authors disclosed no financial relationships relevant to this publication.

Blue rubber bleb nevus syndrome: treatment of lesions in the small intestine with repeated injection of lauromacrogol

Figure 1. A, B, A few blue cutaneous hemangiomatoses on the surface of the feet and body. C, D, Single-balloon enteroscopy revealed many hemangiomas diffused in the small intestine. E-H, The process of the injection of lauromacrogol, such as found lesion, injected lauromacrogol into the hemangioma, the status of hemangioma after injection, hemangioma had regressed and the site had healed after each treatment for 30 days.

A 24-year-old woman presented to our department with a 10-year history of melena. Physical examination discovered blue cutaneous hemangiomatosis 0.5 cm in diameter

on the surface of her feet and body (Fig. 1A and B) (Video 1, available online at www.giejournal.org). The patient’s hemoglobin level at admission was 5.4 g/dL (normal

1274 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5 : 2015

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VideoGIE

This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. 12-17 g/dL), and her mean corpuscular volume was 60 fL (80-100 fL). Single-balloon enteroscopy (SBE) revealed many hemangiomas diffused in the small intestine (Fig. 1C and D). The maximum diameter exceeded 3.0 cm. The case was diagnosed as blue rubber bleb nevus syndrome by these outcomes. The multiple hemangiomas were obliterated by monthly injections of lauromacrogol with SBE. Four SBEs had been performed in a 4-month period. The initial 2 anterograde enteroscopies revealed 12 hemangiomas in the jejunum 100 cm from the angle of Treitz, and the later 2 retrograde enteroscopies found 10 lesions in the terminal ileum. These lesions were injected with lauromacrogol successfully (Fig. 1E-G). The previously treated hemangiomas had completely regressed, and the sites had healed after each treatment for 30 days (Fig. 1H).

The patient had no obvious drop in hemoglobin during the process. There was no fever or abdominal pain after these treatments. We deduced that the treatment to eliminate bleeding for patients with blue rubber bleb nevus syndrome is a feasible approach to remove all lesions in the GI system. DISCLOSURE Z. Wang has ownership interest in Jingling Hospital of Southern Medical Univeristy. X. Yang, L. Wu, B. Yuan, Y. Lu, H. Shi, Y. Wang, and F. Wang have partnerships in Jingling Hospital of Southern Medical Univeristy. All other authors disclosed no financial relationships relevant to this publication. Zhenkai Wang, MD, PhD, Xiaoqian Yang, BS, Lin Wu, PhD, Hui Shi, PhD, Youke Lu, PhD, Boshi Yuan, PhD, Yanxia Wang, BS, Fangyu Wang, PhD, Department of Gastroenterology and Hepatology, Jinling Hospital of Southern Medical University, Nanjing, Jiangsu Province, China

http://dx.doi.org/10.1016/j.gie.2014.08.013

Endoscopic management with over-the-scope clips for intestinal bleeding of Behçet’s disease

Figure 1. A, Endoscopic findings via the stoma revealed an ulcer (approximately 15 mm in diameter) with continuous bleeding. B, Endoscopic findings also revealed a deep ulcer (approximately 10 mm in diameter). The muscle layer was exposed, which could potentially cause a perforation. C, One bleeding ulcer was successfully closed using 2 OTSCs (red and yellow arrows). Because we were unable to aspirate the entire defect into the OTSC mounting cap, we placed 2 OTSCs on the ulcer without incorporating the clips during closure. D, The other deep ulcer was successfully closed using 1 OTSC with grasping forceps (Twingrasper: Ovesco Endoscopy GmbH). E, Three months after treatment, the endoscopic findings revealed mucosal healing of the first ulcer by application of infliximab. F, The endoscopic findings revealed complete closure of the other deep ulcer with 1 OTSC 3 months after treatment.

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Blue rubber bleb nevus syndrome: treatment of lesions in the small intestine with repeated injection of lauromacrogol.

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