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A woman in her 90s with dementia accidentally ingested an unknown amount of calcium chloride–containing desiccant (pH 7–8). Computed tomography (CT) revealed circumferential gastric wall thickening, and upper gastrointestinal endoscopy revealed ulcers with necrotic material extending from the cardia to the greater curvature of the pyloric region, along with erosion of the posterior wall of the descending duodenum. The patient was diagnosed with severe corrosive gastritis and was treated with omeprazole, sucralfate, and antibiotics (SBT/ABPC). Upper gastrointestinal endoscopy performed on hospitalization days 15, 29, and 80 revealed gradual improvement of the ulcers without stenosis, not requiring treatment. Severe injuries caused by the ingestion of strongly alkaline agents, such as chlorine-based bleaches, are well known. However, as in this case, even mildly alkaline agents can cause severe injuries depending on the amount ingested, presence of solid components, and time elapsed after ingestion. Therefore, it is crucial to consider this possibility in clinical practice.

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an effective method for cases where transpapillary approaches to pancreato-biliary diseases are challenging, though serious complications often occur. Here, we report an extremely rare case of delayed biliary hemorrhage due to pseudoaneurysm rupture after EUS-HGS, caused by migration of the placed plastic stent. The patient was pathologically diagnosed with unresectable advanced pancreatic cancer and presented with severe duodenal stenosis and bile duct obstruction. Before chemotherapy, EUS-HGS with a biliary plastic stent (7Fr Type IT stent) was successfully performed without early complications. However, after 46 days, the patient developed massive melena, and computed tomography revealed a biliary hemorrhage within the common bile duct. Imaging revealed that the hepatic end of the plastic stent had migrated from the hepatic hilum to the posterior segment. After 71 days, the patient experienced a recurrent biliary hemorrhage, and an 8 mm pseudoaneurysm was identified in the posterior hepatic region at a location consistent with the migrated hepatic end of the plastic stent. Hemostasis was successfully achieved by emergency transcatheter arterial embolization with N-butyl cyanoacrylate. During the 6 months after the intervention, no recurrence of the pseudoaneurysm was observed, and the patient continued systemic chemotherapy with stable disease control. We suggest that biliary hemorrhage due to pseudoaneurysm rupture, which may be caused by migration of the placed plastic stent, should be considered a life-threatening late complication of EUS-HGS, requiring thorough follow-up.

Alpha-fetoprotein-producing gastric cancer (AFPGC) is a rare histological subtype of gastric cancer that is often diagnosed at an advanced stage. In the present case, an elevated lesion was detected in the gastric antrum during upper gastrointestinal endoscopy screening and diagnosed as early gastric cancer of cT1a. The patient underwent endoscopic submucosal dissection (ESD), and pathological examination showed positive staining for AFP, leading to a diagnosis of AFPGC confined to the intramucosa (pT1a). An additional laparoscopic distal gastrectomy with lymphadenectomy was performed, which revealed no residual tumor and no lymph node metastasis. The patient has remained recurrence-free for 4 years after the additional surgery. Intramucosal gastric cancer with AFP production is extremely rare, and limited data are available regarding the need for additional surgical resection after ESD. Notably, a previous case of metastatic recurrence in AFPGC of cT1a was reported. Therefore, treatment decisions should be made on the basis of a thorough discussion and the patient's full informed consent.

We present a rare and diagnostically challenging case of a pancreatic neuroendocrine tumor (pNET) with intraductal growth into the main pancreatic duct (MPD), complicated by severe thrombocytopenia due to myelodysplastic syndrome. A 37-year-old male presented with thrombocytopenia. Abdominal imaging revealed an 11-mm hypervascular lesion obstructing the MPD in the pancreatic body. The initial serial pancreatic juice aspiration cytological examination (SPACE) demonstrated Class II cytology. Eight months later, the second SPACE revealed Class V cytology. Pancreaticoduodenectomy confirmed pNET G2 with clear intraductal extension. In the postoperative specimen, a portion of the tumor was exposed within the MPD, suggesting Class V cytology. pNETs with intraductal extension (I-pNETs) are rare, as pNETs typically exhibit expansive encapsulated growth. SPACE may be a valuable diagnostic alternative for patients with thrombocytopenia, although its accuracy may depend on factors such as capsular integrity and ductal communication. Tailored diagnostic strategies that balance invasiveness and safety are essential for managing pancreatic tumors in patients with hematological fragility. This case highlights the importance of considering I-pNET in the differential diagnosis of MPD-occupying lesions.

Endoscopic ultrasound-guided rendezvous (EUS-RV) is an alternative technique for patients in whom selective bile duct cannulation (SBDC) has failed during endoscopic retrograde cholangiopancreatography (ERCP). However, EUS-RV has several challenging steps. Herein, we present a method for troubleshooting the EUS-RV using a nasobiliary drainage tube (NBD) in a patient with a large periampullary diverticulum (PAD) and severe gastroptosis. An 80-year-old woman presented with nausea. Contrast-enhanced computed tomography revealed a common bile duct (CBD) stone. Although ERCP was performed twice, the ampulla of Vater (AV) could not be identified due to the large PAD. Therefore, EUS-RV was performed. The CBD was punctured from the descending part of the duodenum. Although a guidewire was advanced through the AV, the PAD hindered guidewire insertion to the anal side of the duodenum. During the switch to duodenoscopy, the guidewire was withdrawn due to gastroptosis. A subsequent attempt to puncture the CBD through the duodenal bulb resulted in guidewire entrapment. To manage the prolonged procedure, a 5-French NBD was temporarily placed in the CBD. An NBD was subsequently inserted into the duodenum via the PAD using esophagogastroduodenoscopy under fluoroscopic guidance after 1 week. After switching to duodenoscopy, SBDC was successful along the NBD that was not withdrawn, and the stone was removed. NBD use in EUS-RV may be effective in difficult cases of guidewire manipulation into the distal duodenum due to PAD and guidewire maintenance due to gastroptosis. Further, NBD is a readily available device, making its use convenient.