Esophagoscopic examination was performed on 402 cases of chronic liver diseases. Varices were detected in 298 cases and classified according to the criteria proposed by Japanese commities on Portal Hypertension (1979). History of variceal bleeding was significantly frequent in the patients with varices associated with R-C signs (hematocystic spot, moderate or severe grade of cherry-red spots and / or red wale marking). The associated teleangiectasia of moderate or severe grade was also frequently detected in the patients with high risk of variceal bleeding. Chronic hepatitis and cirrhotic patients were further examined. Those with F3 varices had a high incidence of splenomegaly and / or ascites. It was also found that they had lower value of indocyanine green plasma disappearance rate (KICG), thrombotests and higher value of intrasplenic pressure. The intrasplenic pressure of the patients with R-C signs were higher than in those without R-C signs. These result suggest that the formation of varices and R-C signs closely associated with the elevation of the intrasplenic pressure.

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The nuclear DNA content of cells from a series of 35 patients with different mucosal excrescent lesions of the stomach including 13 hyperplastic polyps, 10 border-line lesions (A.T.P. ; Atypical epithelium), 5 early & 7 advanced carcinomas, and from 7 normal subjects was estimated by means of Feulgen-DNA cytofluorometry. Hyperplastic polyps showed nearly constant average DNA content and a diploid value without any polyploidy cells over tetraploid. There were two different types, namely normal and abnormal having higher average DNA content than normal with small percentage polyploidy cells, in patients with A.T.P. Generally high DNA content and polyploidy cells were found in patients with carcinoma, although they were widely ranged from nearly normal to high. In most cases of Group V a stem line was located on aneuploidy and in few cases on diploidy, whereas it was found on diploidy in all of patients with Group-I, II, III, IV. There was no direct relationship between the DNA pattern and histological depth of carcinoma. These results indicate that it was not possible to accurately distinguish all border-line lesions from benign or malignant by the DNA pattern, although DNA analysis was, to some degree, beneficial for screening.

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Radiological and endoscopic examinations in the diagnosis of esophageal varices were performed in 50 patients with liver cirrhosis and their diagnostic values were comparatively investigated. Both procedures agreed with each other diagnosis in 37 cases (74 per cent), including 34 cases (68 per cent) with and 3 cases (6 per cent) without esophageal varices. In order to investigate the possible cause of the discordance in the diagnosis between two procedures, the incidence of observer variation in radiological and endoscopic interpretation was fundamentally studied. Firstly, precise barium-contrast examination was carried out in 8 cirrhosis with slight degree of esophageal varices, and observer variation in the radiological evaluation of esophageal varices was studied. The incidence of interindividual error among 3 observers (A, B and C) was 41 per cent besween A and B, 22 per cent between B and C, and 33 per cent between C and A, the mean value being 32 per cent. The incidence of intraindividual error between the first and second interpretation was, on the other hand, 34 per cent in A, 19 per cent in B and 9 per cent in C, the mean value being 21 per cent. Secondly, two well experienced endoscopists independently evaluated 12 cirrhotic patients for esophageal varices during the same endoscopic examination with a Magniflying Endoscope (FES-X6). One detected esophageal varices in 9 of 12 patients (75 per cent), and the other in 11(92 per cent), the interindividual error being 17 per cent merely as to the positive existence of esophageal varices, which markedly increased up to 83 per cent when other parameters such as shape, location and color tone of esophageal varices were comprehensively accounted. The unexpected high incidence of observer variation in both radiological and endoscopic interpretations would be the major cause of the present discordance (36 per cent) between radiological and endoscopic diagnoses of esophageal varices.

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The regional mucosal blood volume in the stomach was measured by reflectance spectrophotometry during endoscopy. We made a three dimensional display and a colour display of the gastric mucosal blood volume based on these measurements with an aid of computer. These functional images were analyzed in patients with thermal injury before appearance of acute gastric mucosal lesions, and in patients with chronic gastric ulcer at various stages of the ulcer healing. Thus, the hemodynamic changes which were not visible in ordinary endoscopic examination, was visualized. We reported the usefulness of a three dimensional display and a colour display of gastric hemodynamic changes for prediction of development and its localization of gastric ulcer in the stomach.

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Development and extension of the atrophic gastritis and intestinal metaplasia in the upper portion of the stomach were investigated histologically by examining 37 specimens obtained by gastrectomy or at autopsy. Results indicated that the atrophic gastritis and intestinal metaplasia spread from the cardiac side toward the lower portion of the stomach with aging. However, the atrophic gastritis and intestinal metaplasia developed more frequently and more intensely in the "transitional zone" between the cardiac and oxyntic gland irea than in the cardiac gland area. Histologically, extensive erosions and regenerative changes were often seen in intestinal metaplasia in the upper portion of the stomach, but Goblet or Paneth cells and well-developed brush boner borders were scarcely detectable.

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The effects of electrohydraulic lithotripsy of biliary tract stones were experimentally and clinically evaluated by using an electrohydraulic unit and a basket-tipped lithotripsy probe which were specially designed by Waltz Co. in West Germany. In vitro experiments, human gallstones of various kinds and sizes were completely crushed by varying an electrohydraulic power and pulse frequency. Electrohydraulic lithotripsy in vivo animal experiments using the rabbit small intestine showed that the procedure was safe without complications in discharging a low or middle grade electrohydraulic power and pulse frequency of the unit, though a high frequency electrohydraulic power might occur an injury or perforation of the rabbit small intestine. These experi-mental results allowed to apply endoscopic electrohydraulic lithotripsy (EEL) in clinical cases for removal of huge biliary tract stones. The EEL was attempted in seven patients with choledocholithiasis following endoscopic sphincterotomy (EST), and was successfully accomplished in six patients without any complications and with complete removal of huge biliary tract stones. In the remaining one, the procedure failed because of unsuccessful catching of a stone by the basket-tipped lithotripsy probe. These results apparently show that EEL is a relatively safe and effective procedure and makes it possible to retrieve huge stones within the common bile duct. The technique can eliminate the limitation of gallstone removal and can enlarge the indications for EST.

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Carcinoid tumors of the stomach are uncommon and very difficult to be diagnosed roentogenologically or endoscopically because of lack of the specific features. We experienced five cases of carcinoid tumor of the stomach including those reported previously (case No3 and 4). We made an effort to find out morphological characteriatics of carcinoid tumors of the stomach by reviewing endoscopic pictures and literatures, but we felt that the differentiation from submucosal tumor, carcinoma, polyp and polyposis was very difficult. We could make a correct diagnosis of carcinoid tumor of the stomach before operation in 3 of 4 cases in which endoscopic biopsy was performed. We thought that biopsy was very useful in the diagnosis of carcinoid tumors of the stomach. Only one patient peresented with flushing and was found to have multiple liver metastases and high values of urinary 5-HIAA, 5-HT and histamine. Two patients were associated with carcinoma of the sigmoid colon. Therefore, it should be stressed that the presence of carcinid tumor should alert the physician to search for a second neoplasm.

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A 50-year-old man was admitted with a shock state due to a gastrointestinal bleeding. Endoscopic examination revealed a small 4 mm mucosal defect covered by blood clot in the corpus. Two days later, massive hemorrhage recurred and the patient was sent to a surgeon. Histological examination disclosed a ruptured artery which was abnormally large and was tortous in the submucosa. At the site of rupture the artery reached the mucosa through the muscularis mucosae. The lesion was described by Gallard in 1884 and by Dieulafoy in 1897. However, there is no agreement on terminology at present. Since the mortality of the patient was high, early diagnosis and prompt surgical treatment was necessiated. Therefore the lesion should be called by an universal name and also should be investigated as one of the gastrointestinal bleeding. We prefer the term "Gallard-Dieulafoy ulcer"

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This is a presentation of a case with a giant ulcer showing the protruding change on its healing process.The patient was 59-year-old male who was admitted to our hospital with chief complaints of severe epigastric pain and hematemesis. X-ray and endoscopic examination of the stomach revealed a giant ulcer on the posterior wall of the gastric angulus.After four weeks of treatment with a new H2-receptor antagonist (Ranitidine), this lesion changed a whitish protrusion without regenerated epithelia. Histologically, it showed granulation tissues with marked increase in capillaries and distinct infiltration of lymphocytes.Subsequently, we observed endoscopically biweekly, and we found that this protrusion had disappeared after twenty-one weeks of treatment.

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Cytomegalic inclusion disease (CMID) in adult is rare, but has recently been paid attention to, as an important infection in critically ill patient. This is a presentation of a case of CMID of stomach associated with Lennert's lymphoma. The patient is a 47-year-old man who was admitted because of fever. Physical examination disclosed lymphadeno-pathy and hepatomegaly. Histological picture of the biopsied lymph node revealed non-Hodgkin's lymphoma. On radiological examination of stomach ulcerative lesions were found along the greater curvature. Endoscopic picture showed eight ulcers, which were covered with white coat and whose margins were demarcated. Biopsied specimens of gastric ulcers showed no malignant changes. The ulcers were followed-up, but didn't chang in number and size in the clinical course. He died on the 107th hospital day and autopsy finding was Lennert's lymphoma. Autopsy findings showed eight ulcers (Ul-III) along the greater curvature of the stomach. Histologically, in the capillary endothelial cells, the glands and the nervous plexus at the base of the ulcers, many cytomegalic inclusion bodies wer found. It is suggested that the ulcers were caused by cytomegalovirus infection because there were no cahnge in number and size, and the rare specific morphology.

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Adenomyomatous hyperplasia of the gallbladder was observed by peritoneoscopic examination in a 42 year-old Japanese man who was suspected of having chronic hepatitis. Drip infusion cholecystography and an echogram of the abdomen revealed no abnormal findings. However, since the presence of a malignant lesion was indicated by celiac angiography the gallbladder was resected. Histologically it was diagnosed as adenomyamatous hyperplasia. In the last ten years, 236 cases of adenomyomatous hyperplasia of the gallbladder have been reported in Japan. Only two cases including this case, were observed by peritoneoscopy. There is a possibility that peritoneoscopy may be valuable in the diagnosis of adenomyomatous hyperplasia.

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Primary carcinoma of the small intestine has been reported rarely because it is an uncommon disease itself and the examination is difficult. Recent advances of intestinal endoscopy make it possible to diagnose cancer of the small intestine. Our case was also diagnosed endoscopically. The patient, 66-year-old male, was admitted on July 28, 1981, with complaints of anemia for neary one year and a palpable tumor. A hard mass was palpable in the umbilical region. Laboratory data on the admission revealed severe anemia and stool positive for occult blood. Upper GI X-ray, gastroduodenoscopy and ERCP were normal. CT and echogram showed a large tumor in the middle of the abdominal cavity. With these findings jejunal carcinoma was suspected. Selective small intestinal radiogaraphy revealed a localized stricture with overhanging edges and huge ulceration in the jejunum about 20 cm distal from the duodeno-jejunal flexure. Small intestinal endoscopy with the Olympus SIF endoscopy showed cancer infiltration into the jejunal mucosa. Endoscopic finding was very similar to that of Borrmann type 3 gastric cancer. Biopsy specimens revealed tubular adenocarcinoma. The patient was operated on. The resected tumor was 16×8×10cm.

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Infection of Yersinia enterocolitica and Anisakis leads to acute terminal ileitis, but the exact pathophysiology is still unknown. We endoscopically examined the terminal ileum in 4 cases of acute terminal ileitis, and observed repeatedly the clinical courses of the lesion in three of them. All the cases complained of fever, pain of the right lower abdomen and diarrhea. In one case, stool culture yielded Yersinia enterocolitica. Other three cases were diagnosed as acute terminal ileitis by the radiological findings, the endoscopical aspects and the clinical pictures. The radiological findings were fine irregularity of the ileal wall, unshapely shadow resembled ulcerations, irregular enlargement of mucosal folds and small scattered filling defects, and in one case, enlargement of the Bauhin's valve. In acute stage the endoscopical aspects of the terminal ileum were ulcerations and erosions. Only one case showed cobble stone appearance. In healing stage, ulcers and erosions disappeared, and small scattered nodules were obseryed, and those were thought lymphoid hyperplasia by biopsyspecimen. After 3-6 months, we obseryed normal endoscopical aspects of the terminal ileum in 3 cases. Thus far, the recurrence of the diseases does not occur. We reported chiefly the endoscopical aspects of 4 cases of acute terminal ileitis.

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Case 1. A 56-year-old man visited our hospital with right lower abdominal pain. Barium enema study and colonofiberscopic examination showed a smooth and caterpillar-like semipedunculated lesion of the cecum (Figure 1, 2). Under the diagnosis of a submucosal tumor colonof iberscopic polypectomy was underwent and the resected specimen showed a submucosal lipoma (Figure 3). Case 2. A 74-year-old woman visited our hospital with anal discomfort. Barium enema study and colonof iberscopic examination showed a smooth, yellowish and ovoid semipedun-culated lesion of the cecum (Figure4, 5). Under the diagnosis of a submucosal lipoma, colonof iberscopic polypectomy was underwent and the resected specimen showed a submucosal lipoma (Figure 6). Lipoma of the large intestine has been reported amounting to about 100 cases throughout Japan. Thirty-two cases were observed endoscopically and endoscopic polypectomy was performed in only 11 cases (Table 1). As most cases of lipoma of the large intestine reported are semipedunculated or pedunculated, the endoscopic polypectomy may be the main therapeutic method of the disease under the careful selection of the indication.

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