In the past ten years, using various types of peritoneoscope and light source produced by Machida Company, a total of 962 cases of peritoneoscopic examinations were carried out on patients with hepatobiliary diseases, ascites of unknown causes and abdominal tumors. Among 962 cases of peritoneo-scopy, 241 cases of the new growth of the liver were obtained. Among a total of 241 cases of liver malignacy, there were 180 (74.7%) cases of hepatocellular carcinoma (HCC) ; 47 (19.5%) cases of meta-static carcinoma of the liver; 7 (2.9%) cases of cholangiocellular carcinoma. A total of 147 (81.7%) out of 180 cases of HCC were observed associated with liver cirrhosis. HCC was male predominant, the ratio being 8.5:1 between the male and the female. The predominant age of HCC ranged from 40 to 60. The main peritoneoscopic finding of HCC was that the protruding main tumor was covered by the greater omentum in about one fourth of the patients with HCC. Peritoneoscopically, we classified HCC into massive, nodular, diffuse and unclassified types. We think that the peritoneoscopic classification is helpful for determining the resectability of the tumor. Through the experiences with 241 cases of peri-toneoscopic diagnosis of the new growth of the liver, we have been trying to make the diagnostic criteri-a of HCC and other neoplasm of the liver. The establishment of the diagnostic criteria can easily make a differential diagnosis of HCC from other liver diseases.

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It is generally accepted that pancreatic exocrine function disorders are seen in 10 to 20 per cent of postgastrectomy patients In this condition high amylase activities in the urine, increased amylase creatinine clearance ratio and derceased pancreatic exocrine function measured by the pancreozymin-secretin test were reported. The disorders were thought to be caused by the various damages to the pancreas which occured just after biliary or gastric surgery. The pancreatic exocrine dysfunction after gastrectomy showed an improvement with time and recovered nearly to the normal level by three to four months after surgery. In this study, endoscopic retrograde cholangiopancreatography (ERCP) was performed in 22 patients who underwent Billroth-I gastrectomy one to 20 years before this examination. The pancreatic exocrine function diagnostant (PFD) test, measurement of amylase activities in the urine and the serum, and gastric emptying test were also performed on the same patients. The results are summerized as follows: 1) Ten of 22 patients (45.5%) showed some changes in the pancreatic duct which resembled those of chronic pancreatitis. 2) The ductal pathology could be classified in to three different stages; “mild”, “mod-erate” and “severe” abnormality. In 10 patients with ductal changes, 5 showed “mild” 4 showed “moderate” and one showed “severe” change. 3) Four of 6 patients with abnormal pancreatic ducts on ERP showed abnormal values in the PFD test on the other hand only one of 7 with normal pancreatic ducts showed a slight decrease in the PFD test. Therefore, it is assumed that the patients with abnormal pancreatic ducts on ERP showed disorders of the pancreatic exocrine function. 4) The longer the duration of postgastrectomy state, the higher the incidence of ductal abnormality (P<0.025). 5) The gastric emptying was more rapid in the patients with “abnormal” pancreatic ducts than in those with “normal” pancreatic ducts. On the basis of these results in postgastrectomy patients, pancreaticocibal asynchrony may occur because of rapid gastric emptying and hypermotility of the small intestine. This condition may cause impairment of CCK-PZ and secretin secretion. Then, it is assumed that malabsorption due to pancreaticocibal asynchrony and reduced pancreatic exocrine function probably cause gradual pancreatic atrophy and / or fibrosis.

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One of the problems on the diagnosis of early gastric carcinoma is the determination of the extent of the carcinoma while the diagnosis of the extent of the “superficial spread-ing type of early carcinoma of the stomach” (abreviated as SSC in the following sentenses) is still difficult. In this study, we performed a clinicopathological study of proximally ac-companied IIb using depressed type of SSC, in which it was difficult to diagnose proximal infiltration. The SSC was defined as the early carcinoma with a squaremeasure of over 5 × 5 cm2. We experienced 63 cases of depressed SSC in the past 12 years. The results are as follows: Pattern of proximal infiltration of SSC was divided into 2 types; with accompanied IIb and without accompanied IIb. Accompanied IIb was recognized at 26 cases (41.3%) of the total 63. Still more, these proximally accompanied llb were classified into 2 types; with covering foveolar epithelium and without covering foveolar epithelium. Comparative study between the histology and endoscopic findings showed that the cases without covering foveolar epithelium had some endoscopic findings, e. g. redness and discoloration, hemorrhage, and erosion. However the cases with covering foveolar epithelium at proximally accompanied IIb had little findings on endoscopy, suggesting the difficulty to discern. Most of the proximal infiltration of the depressed SSC were located at the intermediate zone. This fact may indicate that the endoscopic observation of the intermediate zone is important.

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We experienced fourteen cases of drug-induced colitis which occurred after administra-tion of antibiotics for past two years. Drugs given in these cases were mainly ABPC. Chief complaint was bloody stool associated with severe abdominal pain. This report is to evaluate these cases from the standpoint of endoscopic appearance as well as clinical and laboratory findings. Following results were obtained; 1) This disease is common in females, and found in all ages. Common cold and op-eration were main causes for which antibiotics was administered. There were no differ-ences among seasons concerning the onset of this disease. 2) On average, bloody stools developed on the seventh day after antibiotics was given. Frequency of the bloody stools was usually more than ten times a day. Symptoms com-monly inproved within six days after discontinuance of antibiotics. 3) The characteristic appearances of endoscopic examination done at the stage when bloody stools developed were redness, edema and erosion. No ulceration or formation of pseudomembrane was found. On dyeing endoscopy, various types of aphthoid erosion were observed. However, there was no correlation between the type of aphthoid erosion and the stage of the disease. Main lesions were found in the descending and sigmoid colon. Only slight changes were found in the rectum. There findings disappeared shortly after the discontinuance of antibiotics. 4) Klebsiella oxytoca was detected in the stool in more than half of the cases. There- fore, it was presumed that K. oxytoca played an important role as one of the etiologic fac-tors in this disease.

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During the period from February 1965 to April 1981, we experienced 7 patients with carcinoma of the pancreas smaller than 3 cm in maximum diameter, defined as small pan-creatic cancer. All of the 7 cases presented with jaundice and their tumors were located in the pan-creatic head. Pancreatogram was obtained in six cases, in which the findings were a marked stenosis with poorly visualized branches in four cases and an obstruction of the main pancreatic duct in two cases. These findings were essentially identical to those seen in advanced pan-creatic cancers, but the involvement was confined to a short segment of the main pancre-atic duct. All of the patients were operated on (pancreatoduodenectomy in 5 cases and total pancreatectomy in 2 cases) and were found to have either lymph node metastasis, duodenal or retroperitoneal invasion microscopically. The diagnosis of pancreatic cancers by ERCP is not so difficult in almost all cases even in patients with a small pancreatic cancer. In cases in which the diagnosis is indeter-minate despite other diagnostic modalities are utilized, laparotomy should be performed to detect small and curable pancreatic cancers. Apart from this approach, it is most important to establish the screening methods for pancreatic cancer which may increase the frequency of these lesions.

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It is well known that emergency endoscopy of upper G-I tract is valuable for the diagnosis and management of acute gastrointestinal bleeding. However, emergency endoscopy is not widely applied to colorectal diseases because of the technical difficulties to introduce the scope and to inspect the lesion during acute bleeding. Therefore, the definition of emer-gency colonoscopy is not established yet. During the last 6 years and 9 months, colonoscopy was performed to 113 cases of acute anal bleeding probably from the lower intestine within 7 days of its onset. Afetr a single enema with 100 ml glycerin or without any preparation, colonoscopy was performed in a conventional manner. In 94 cases (83.2%), the causes of bleeding were diagnosed correctly by emergency colonoscopy. In 11 cases (9.7%), some lesions were found out, but these causes of hemorrhage were not able to confirmed by this technique because of no more blood in the intestine and / or subsidence of inflammation around the lesions. On the other hand, in two cases (1.8%), the lesions were misdiagnosed, and any lesions were not able to be found out in 6 cases (5.3%). When the endoscopic examination was per-formed within 3 days after bleeding, the diagnostic accuracy was better than the delayed examined group; i. e. 89.6% in confirming the bleeding focus. Consequently, it is emphasized that emergency colonoscopy should be performed within 3 days after the onset of anal hemorrhage for the correct diagnosis and management of the bleeding.

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During the recent years, the skinny, forward-viewing fiberscope as a panendoscope has been developed and used by a large number of endoscopists. The authors carried out endoscopic examinations of the upper gastrointestinal tracts using the Olympus GIF-P2 Fiberscope (Olympus Optical, Co.). This paper presents the results of the authors' discussions on whether it was possible to observe and photograph all parts of upper gastrointestinal tract (esophagus, stomach and duodenum by a series of new methods (in the sequence of observation and photography). The photography was conducted in the sequence of esophagus (three frames from No. 1 to 3), E-C junction (two frames from No. 4 to 5), corpus (11 frames from No. 6 to 16), angle and its periphery (eight frames from No. 17 to 24), antrum (eight frames from No. 25 to 30 and from 39 to 40), duodenal cap (six frames from No. 31 to 36) and the second portion of duodenum (two frames from No. 37 to 38). Two 20-exposure films were used for this series. As a result, the authors could observe every part of the upper gastrointestinal tract with the aid of GIF-P 2, skinny fiberscope with a highly flexible short tip, which is capable of turning in all directions. Furthermore, the authors recorded the photographed regions on the schematic diagram of the stomach to see which regions of the stomach has been photographed and came up with the perfect photography of the entire regions of the stomach. In addition, the recurrent observation and photography of corpus and antrum centering on the angle has made it possible to analyze, with ease, such a lesion like a wide IIc with minor change on the mucosal surface. Therefore, observation and photography with nearly the same degree of precision as by a sibe-viewing fiberscope was feasible. The skinny, forward-viewing fiberscope GIF-P2 has the characteristics of panendoscope. It is useful not only in the screening test but also for the standard clinical procedure. Moreover, because of its skinny fiberscope, the pain to the patients is minimized.

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GIF-Qw with an extra-wide visual angle, a further improved type of GIF-Q, was ap-plied to 1, 078 cases of upper G-I endoscopy. The introduction of this endoscope into patients was as easy as in the thin endoscopes, presenting the clear views without any blind point from the esophagus and gastric lumen to the duodenal bulb. The manipulation in the stomach was also excellent with easy U-or J-turn observations and this scope was able to be pulled into the esophagus on looking up in the cardia with the inversion of the scope. The duodenal bulb was also observed without marked blind points, and it was easy for us to introduce the scope into the descending part of the duodenum. The en face view of the papilla of Vater was, however, inferior to the side-view endoscoped. The examina-tion of the aberration revealed a barrel distortion due to the extra-wide angle of the view in observing a plane test chart. In fact, the en face view of the postrior wall of the middle or lower body of the stomach which is regarded as a weak point of the forward-view endo-scope, became not difficult and observation of the greater curvature immediately beyond the pyloric ring was also easy. The biopsy channel of this scope has a relatigely small diameter of 2 mm, but it had no problem in the conventional diagnosis.

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Esophageal cancer rarely developes in esophageal diverticulum; only 45 such cases have been reported in the world literature. A 67 year old man was admitted to Kyushu Unigersity Hospital with a chief complaint of epigastralgia. An upper GI series revealed an ulcer in the gastric angle and a diverticulum in the mid-portion of the esophagus. Immediately afterwards, endoscopy using a wide forward-viewing panendoscope revealed a small elevated lesion containing a shallow ulcer in the e-sophageal diverticulum and chronic peptic ulcer in the gastric angle. The former lesion was considered to be malignant, and it was biopsied. The resected specimen consisted of a round slightly elevated lesion 7 mm in diameter containing central ulcer. Histologically, the tumor was a well differentiated squamous cell carcinoma which had directly invaded the adventitia, despite of its small size. Therefore post-operative radiation therapy was performed.

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A 75-year-old male in patient with intracranial hematoma complained of dysphagia 3 months after the start of medical treatment. X-ray and esophagoscopic examinations showed a stenosis in the region from Im to Ei but no abnormalities on the esophageal mucosa. Surgical operation was performed for a suspicion of malignant disease, Gross pathological findings showed that the esophageal wall was hypertrophied and small erosions were disseminated in the dark-reddish, violet mucous membrane of the steno-tic region. Histopathological examination showed non-specific inflammation, indicating inflamma-tory cell infiltration and severe submucosal fibrosis in all the layers of the esophageal wall. In this patient, inflammatory changes are considered to be due to a nasogastric tube for feeding early in the hospitalization period.

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A case of achalasia, 54 year old female was treated with a new pneumatic dilator which is attached to the panendoscope (GIF-P2, Olympus). Two size of the dilators were made of silicon rubber covered with silicon mesh by which the balloon does not exceed (1) 30 mm and (2) 40 mm in diameter when they are inflated. The introduction of the di-later to the narrow segment and its dilatation was carried out under visual control (Figure 5). The treatment was repeated 4 times with inflation pressure of 200 mm Hg to 280 mm Hg. The first 2 treatment was done with 30 mm size balloon and further 2 treatment was done with 40 mm size balloon. In Figure 1, the left picture shows the esphagus before the treatment and right one shows the changes one month after the treatment. The size of the esophagus decreased from 56 mm to 35 mm. This method facilitate the introduction of the balloon to the narrow segment and is safer than the conventional method, because the all the procedure can carried out under visual control.

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The patient was a 57-year-old man, He was pricked with a thorn at the right sole of fourth toe, and the wound was hard to heal. But pigmentation or tumor did not appear at the lesion. At this time histopathological examination was not done. Afetrwards, the tumor appeared at the right inguinal region and grew larger up to about an egg-size The tumor was diagnosed histologically as metastatic malignant melanoma of a lymph node. So he was hospitalized to our dermatologic department and received chemotherapy (DTIC 500 mg, ACNU 100 mg and VCR 1 mg-one cure). After about one month, he feeled heart-burn and so visited our department. At the first endoscopic examination, there was a small polypoid lesion on the posterior wall of the greater curvature at the upper body of the stomach. The lesion showed a bull's eye form lesion with central black color covered by normal mucosa. Endoscopic diagnosis was metastatic malignant melanoma of the stomach. After anti-cancer chemotherapy, the slope became gradually gentle. At last the lesion was flattened and showed only pigmenta-tion, after five months from the first endoscopic examination; about seven months from the first chemotherapy. Endoscopic biopsy and cytology by thorny needle done at the first endoscopic examination revealed metastatic malignant melanoma of the stomach with melanin pigments which were confirmed by Masson stain. The primary focus may or may not be the right sole of the fourth toe with wound. Now, the patient was been in a good course for about two years.

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This report described a case of 52-year-old female patient with pernicious anemia com-plicating gastric cancer and hypothyroidism. She was diagnosed to have pernicious anemia 11 years ago at Asahikawa Municipal Hospital, and had been followed up with X-ray and endoscopic examination annually until 3 years ago. She was admitted to our hospital because of general fatigue and upper abdominal pain. Gastroendoscopic examination revealed a Borrmann II type tumor on the greater curvature of the upper gastric body, which was subsequently confirmed by biopsy as poorly differenti-ated adenocarcinoma. Furthermore, laboratory findings showed hypothyroidism and microsome test was 6402 dils positive. In the past history, she had been diagnosed to have Graves' disease, treated with antithyroid drugs our presumptive diagnosis was Hashimoto's thyroiditis as a cause of hypothyroidism. The autoimmune mechanism was therefore assumed to be responsible for this case. We reported here a rare case of pernicious anemia associated with gastric cancer and hypothyroidism.

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A case of 52-year-old female with hypoplasia of body and tail of the pancreas was reported. She had mild diabetes mellitus and Pancreozymin Secretin test showed a low level of bicarbonate secretion. Only the pancreas head was imaged by pancreas scintiscan and com-puted tomography. Endoscopic Retrograde Cholangio-Pancreatography showed the defect of the main pancreatic duct with arch formation in the pancreas head; stenosis, obstruction, irregularity of the main pancreatic duct and abnormality of branch ducts were not observed. It is considered that this may be a case of the hypoplasia of body and tail of the pancreas, although fatty degeneration, atrophy or fibrosis of body and tail of the pancreas are not completely excluded.

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A-75-year-old male was admitted to our hospital because of anorexia. Gastroduodenal endoscopy and hypotonic duodenography revealed a small polypoid lesion in the 2nd por-tion of the duodenum. Endoscopic polypectomy was performed for confirming the diag-nosis. The resected tumor, measuring 15 × 11 × 6 mm was histologically diagnosed as a be-nign submucosal lipoma. Sixteen cases of duodenal lipoma reported in Japanese litarature were analysed. Female definitely outnumbered male (female 12 : male 4), and most of them are of middle to old age. The commonest localization of the duodenal lipoma is the 2nd portion. There were no symptome specific for the lipoma and they were usualy found by chance. In 3 cases, endoscopic polypectomy was performed, which was useful for diagno-sis and therapy. Careful proceduare will be needed for endoscopic polypectomy because of its high risk of perforation.

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This study is to present a case of Crohn's disease for whom an extensive small intestine was removed, and also to compare X-ray and endoscopic findings of the involved proximal lesion with findings of the operated material. Patient was 22-year-old male who was admit-ted to Osaka Medical College with chief complaints of abdominal pain and diarrhea for 2 years' duration. Diagnosis of Crohn's disease was made from the characteristic X-ray find-ings of the small intestine. In spite of medical treatments with salazopyrin, EDAC and IVH of two months, no remarkable improvement was observed and operation was performed. During the operation, endoscopic examination was done in order to determine the extent of the involved proximal segment. The findings of X-ray and endoscopic examinations were compared with those of operated material. X-ray films of the involved proximal segment demonstrated aphthoid ulcers which were suggested by conversion of the mucosal folds. While, endoscopic findings were scattered small-sized polyps, and ulceration accompanied by conversion of the mucosal folds. The small intestine was resected 10 cm proximal to the involved seg-ment observed by endoscopic examination. These findings shown by endoscopic examin-ion were almost consistent with those of the operated material, therefore, it is concluded that endoscopic examination during the operation was quite valuable procedure for determin-ing the extent of the involved proximal segment. In addition, indication of operation, and postoperative recurrence of Crohn's disease were mentioned.

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A 58-year-old woman was admitted to our hospital for the further examination of hem-angioma of the liver. While the sigmoid colon cancer was resected a half year ago, the pre-sence of hemangioma of the liver was found. In our hospital, extensive examination was car-ried out. Liver scintigram showed a defect in the left lobe of the liver. Abdominal ultra-sonogram showed a tumor with multicystic echogram in the left lobe of the liver. The celiac angiography showed vascular lakes fed by the left hepatic artery. In the venous phase, it showed tumor stains in the left lobe of the liver. Peritoneoscopic pictures showed a whitish-yellow tumor in the same place. The tumor was 11 × 7 × 5cm in size, and 455 gr in weight. Cut surfaces were cavernous-like containing blood, and microscopic examination revealed hemangioma of the liver with different sizes of the vascular lumen covered with flat endothelial cells. We report here a case with a hemangioma of the liver resected after the diagnosis by angiography and peritoneoscopy.

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This report is to present two cases of endometriosis involving the sigmoid colon, and to discuss the diagnostic value of biopsy under direct-vision. First case was 29-year-old housewife who had rectal bleeding related to menstrual cycle. Relatively smooth, nodular mass with marked redness was found 15cm proximal to the anus on endoscopic examination. Biopsy specimen taken from the lesion revealed endometrial glands surrounded by the stroma in the submucosal layer. Second case was 37-year-old female who developed rectal bleeding associated with intermittent lower abdominal pain. A thumb-sized mass was palpable on pelvic examination. Digital examination revealed a palpable mass with slight ten-derness at 10cm from the anus. Romanoscopic examination revealed a somewhat pale mucosa which showed irregular surface and bled easily by contact. Tortuous endometrial glands consisting of columnar cells were surrounded by stromal cells by biopsied specimen. In most of cases of endometriosis of the colon, the mucosa was intact, so it was only four cases including our two cases that endometrial glands were found by biopsy during the past six years. The chararteristic symptom of these four cases was rectal bleeding, which strongly suggested invasion of the endometriosis into the mucosa. Therefore, we might say that biopsy under directvision played an important role in these case to confirm the diagnosis.

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