During the past 8 years 115 cases of the M-W syndrome were experienced. The age distribution ranged from 22 to 83, with an average of 51.5. Male cases were 92.2% of total. As the direct etiology of the M-W syndrome, retching or vomiting was seen in 98.3% of the cases. Occurence of the M-W syndrome after alcohol ingestion was 50.4% of the cases, but daily drinkers were 72.2% of the cases. Most of the tears were located in stomach (79.2%), in which 51.5% of the tears were observed on the lesser curvature. Forty seven (92.2%) out of 51 cases which were examined histologically were accompanied with atrophic gastritis. Only 15 among 112 cases (13.4%) showed a complication of definite hiatal hernia. In conclusion, It is speculated that chronic atrophic gastritis is the most important predisposing factor.

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Experimental studies were performed in order to make sure pathogenesis of the Mallory-Weiss syndrome. 1) The prolapse of the gastric mucosa into the esophagus was observed by endoscopic cinefilm at the anterior wall near the greater curvature as the morphological change at the cardia due to retching or vomiting. 2) The intragastric pressure caused by retching or vomiting was from 170 to 290 cm H₂O (an average of 231 Cm H₂O). 3) The tears were produced in 10 anesthetized dogs due to distending the stomach with air. The intragastric pressures required to produce the tear were from 190 to 210 Cm H₂O (an average of 200 Cm H₂O), the pressures of perforation were from 190 to 270 Cm H₂O (an average of 232 Cm H₂O). These longitudinal mucosal tears were observed at the cardia and on the lesser curvature, and they were amazingly similar to the Mallory-Weiss tear in human. In conclusion, the location of the tears may be regulated by anatomical and histological factors.

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Ultrasonic endoscope is extremely useful for judgement of the effect after laser irradiation to early gastric cancer. The regions of coagulaed degeneration and necrosis irradiated by Nd-YAG laser are visualized hyper echoic on the image of an ultrasonic endoscope. By using ultrasonic endoscope immediately after laser therapy, we can correctly diagnose the area and depth of the effect of laser irradiation. We can judge laser therapy for early gastric cancer to be effective when a low echoic area of cancer lesion is observed to change to a hyper echoic region, or when a hyper echoic region is recognized to reach the submucosal layer. Until now, it has been difficult to diagnose the effect after laser irradiation whether cancer celles remain on the border or below of laser irradiated area. But using ultrasonic endoscope together with laser endoscope, we could solve these problems and treat early gastric cancer by laser photocoagulation more precisely.

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In this report, an actual condition of colonoscopy in an average hospital in Japan was investigated. During the last 5 years, 1083 cases (1351 times) of colonoscopy were perfor-med in Yokohama National Hospital. Age distribution of them is showed in Figure 1. The 4th and the 5th decade formed 50% of them with male preponderance. Of symptoms, hematochezia, abdominal pain, diarrhea were prominent. Diagnosis of them are presented on Table 2. The rate of abnormality was 66.4%, and polyp, cancer, diverticulosis, ulcerative colitis were principal diseases. In comparison with barium enema examination, colonoscopy was better in diagnosis of colon diseases especially in polyp and acute colitis except in diverticulosis. As colon disturbances have remarkablly increased yearly, so training of colonoscopist should be a present need.

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A new technique to evaluate gastric mucosal blood flow (GMBF) in dog by thermal diffusion method was introduced in this report. This method uses a thermal diffusion probe constructed from a peltier stack, which we calibrated against hydrogen clearence technique. The probe was surgically placed on the canine gastric mucosal surface and the stack was activated and temperature difference between two plates was recorded in terms of millivolts. Using this method, we checked changes of GMBF induced by several drugs or procedure and the following results were obtained. 1) The clearence curve obtained by electrochemically ganerated hydrogen gas clearence method is almost semilogarithmic curve. So we can calculated blood flow value by this method. 2) GMBF showed a gradual increase a few minutes after AOC tetrapeptide application intravenously (8μg/kg/hs), whereas by hydrogen clearence method, GMBF was shown no increase. 3) By ligation of celiac axis, GMBF decreased and by infusion of Vasopressin (0.5 unit/kg/hs) it also showed a manifest decrease. After cardiac arrest induced by rapid injection of potassium chloride, the continuous line showed a blood flow decrease and finally took a steady state. 4) In these states the data obtained by thermal diffusion method and hydrogen clearence method showed a good correlation (r=0.95, p<0 .001). In many aspects, further evaluation of the validity of this method was needed. From these results, it is concluded that this method is useful to check the continuous change of GMBF and has the merit that it is not affected by the presence of hydrogen ion.

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Ureterosigmoidostomy has been used as a measns of supravesical urinary diversion for both benign and malignant diseases of the urinary bladder. Attention is drawn to the occurrence of colonic polypoid lesions at the site of ureterosigmoidostomy. Colonic mucosa of 29 cases undergone ureterosigmoidostomy were studied endoscopically, histologically and histochemically. (1) The age range of 29 patients (22 male, 7 female) was 35 to 78 (mean 61) years. (2) Endoscopical examination of the anastomotic site showed depressed type (9 cases, 24%), flat-elevated type(7 cases, 20%) and elevated type (19 cases, 51%). The most of the elevated type were subpedunculated polypoid lesions. (3) Histologically the polypoid lesions were inflammatory granuloma. The surround-ing mucosa of the polypoid lesions was endoscopically essentially normal, but histologically, edema, slightly inflammatory cell infiltration and an increase of Paneth's cells were revealed. (4) Endoscopic biopsies were obtained from the polypoid lesions and the surrounding mucosa at pre and postoperation of ureterosigmoidostomy. Biopsy specimens were stained with high iron diamine-alcian blue pH 2.5 (HID-AB). In preoperation group, the mucin in the goblet cells was a sulphomucin dominant as well as that of normal control. In postoperation group, however, the mucin was a sialomucin dominant.

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In the last 13 years, 201 patients with carcinoma of the extrahepatic bile ducts were examined by Endoscopic Retrograde Cholangiopancreatography (ERCP). The diagnosis of 81 patients were confirmed by surgery, and 19 patients underwent radical operation including 3 cases free from invasion to the outer layer of the wall of bile duct, so called early stage cancer. ERC findings were divided into six types based on the shape of the lesion. The resectable tumors were most frequent in patients with either clubshaped type 29.2% (7 of 24) or filling defect type 50.0% (2 of 4). The tumor of the early stage were less than 2.0 cm in diameter and 11 patients of the 16 cases with advanced cancer are larger than 2.0 cm in diameter (68.8%). Macroscopicaly, the tumor in the early stage appeared papillary type or tubular type, but in the advanced stage invasively. Only two patients had a long survival more than 5 years. One of them, with early cancer, is still alive at 7 years and 4 months after operation. ERCP findings of the carcinoma of the extrahepatic bile duct suggest the size of the tumor, macroscopic findings and possibility of the radical operation.

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We performed endoscopic ultrasonography (EUS) in 9 cases suspected gastric or esophageal submucosal tumor by X-ray and endoscopic examination. EUS demonstrated gastric submucosal tumor in 6 cases and esophageal submucosal tumor in 3 cases. In 8 of 9 cases, the tumor was visualized as a low echoic tumor which grew from the proper muscle, and in 1 case, tumor as cystic echo in the submucosal layer. Therefore, the definite diagnosis of the submucosal tumor in all cases was able to be obtained by EUS. We also investigated on the development of the submucosal tumor by EUS. As the results, intra-esophageal or intra-gastric development was recognized in 3 cases and extra-esophageal or extra-gastric development was done in 4 cases. In other 2 cases, one showed intramural, and another one was intra- and extra-gastric development. Surgical operation were performed in only two cases which were diagnosed as leiomyoma histologically. However, the internal echo of the tumor was even in one case, and uneven in another case. It is concluded that endoscopic ultrasonography is the most useful procedure which gives a definite diagnosis, the development of tumor and the determination of histological origin of the submucosal tumor before operation. However, further investigation is needed for the differential diagnosis of benign or malignant tumor in the future.

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Between 1961 and 1983, 1207 cases of early gastric cancer were resected at our hospital. Out of 1207, 78 lesions (6.5%) showed benign appearance ; in which were included 8 cases of the type IIb (61.5%) and 6 cases of the type III+IIc (30.0%). Such cases have been increasing year by year. From April to October in 1984, 1775 lesions were biopsied. Out of 1775, 272 lesions were diagnosed as grade C (low suspicion) and 1644 lesions as grade D (benign) Fifty three lesions (19.5%) in grade C were diagnosed as malignancy by biopsic examinations. On the other hand, in grade D only 2 lesions (0.1%) were cancerous. All were depressed type with ulcerative change. With endoscopic Congo red-methylene blue test, cancerous lesions were observed as bleeched areas. Diagnostic accuracy of early gastric cancer by this method was superior to that by the routine endoscopic examination.

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We used a new type "TV-Endoscope" which used the method of micro-TV-camera without fiber optic bundle for imaging. A light-sensitive charge coupled device (CCD) was housed in the tip of the scope and this CCD worked as TV-camera. The signals from CCD were transformed by a videoprocessor and displayed on a TV-monitor. After the basic investigations of mechanic and safety, we applied this scope on 63 patients for upper GI endoscopy. The TV-monitor image and photographs were excellent, and the instrument system was thought to be acceptable for diagnostic and therapeutic endoscopy. This scope has unique advantage with regard to documentation, demonstration, consultation and training. And, the TV-Endoscope as electronic endoscope may have posibilities such as computer enhancement of the image, computer analysis of findings and space-saving of inf ormations using floppy disks.

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We evaluated the clinical significance of common bile duct stenosis occurring with chronic pancreatitis, comparing the exocrine and endocrine functions and the pancreatograms of patients with stenosis and those without stenosis. Common bile duct stenosis was discovered in 39 out of 102 patients (38%) with chronic pancreatitis in which cholangiograms were available. Generally, a large number of patients with stenosis showed exocrine and endocrine function more impaired than those without stenosis, and the occurence of common bile duct stenosis increased as the classification according to grade based on pancreatogram advanced. On the other hand, 15 out of 44 patients who could not be diagnosed as having advanced pancreatitis using the pancreatogram as the only criterion also showed common bile duct stenosis, and their pancreatic exocrine and endocrine functions usually were revealed as more impaired when compaired with those of 29 other patients without stenosis. As mentioned above, on the basis of the pancreatogram alone, the grade of chronic pancreatitis is occasionally regarded as lower in some patients. In such cases, it would be important to acertain whether or not there is common bile duct stenosis.

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Since April 1982, We have tried screening of sigmoid colon by fiberscopy on healthcheck staying overnight. In two years until March 1984, the number of the examine was 708 cases, 584 were male and 124 were female. The test was performed in the morning on the second day. A laxative was administered at night on the first day. Of the 708 patients, one did not want to be tested, 6 patients had anal lesion being an obstacle to the test, and sigmoidofiberscopy was performed on 701 cases. Colon cancer was detected in two cases, and they were of the early cancer. The number of cases with colon polyp was 73, 94 lesions, diverticulum 6 cases and colitis 2 cases. Overall rate of pathological lesions detected was 11.8% (83 cases of 701). As sigmoidscopy is an easy technique comparing with total colonoscopy, it is concluded that sigmoidofiberscopy is useful for detecting early colon cancer on health-check.

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The patient was a 69-year-old woman with a complaint of epigastric discomfort, who had been previously pointed out to have a submucosal tumor of the stomach. Radiological and endoscopic examination revealed an elevated lesion with irregularshaped excavation on the anterior wall of the gastric corpus (Figure 1, 2). Possibility to be a submucosal tumor was considered, but diagnosis of this lesion by means of endoscopic biopsy was group V, unexpectedly. Subtotal gastrectomy was performed. The lesion, 2.5 cm in the largest diameter, looked like a submucosal tumor macroscopically (Figure 3). Pathological examination revealed undifferentiated adenocarcinoma, with an invasion to sm. Cancerous infiltration was limited within the excavated area in the mucosal layer, and limited within the sharply circumscribed mass, in which cancer cells were involved with a remarkable lymphoid hyperplasia, in the submucosal layer (Figure 4). These findings led to the diagnosis of a so-called gastric cancer with lymphoid stroma which was known to have a favorable prognosis. Change in its shape could not be recognized fundamentally, and an increase in its largest diameter was only 5mm during three years retrospectively (Figure 5, 6). Diagnosis by means of the 4 times of previous biopsy was Group I or II invariably. The patient is alive about 15 months after the operation. The present case is considered to be valuable to evaluate the growth rate and the prognosis of a gastric cancer with lymphoid stroma.

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A 77 years old man had a sudden onset of an epigastric pain and melena in the course of acute respiratory failure. The urgent endoscopy showed an irregular shaped ulcer covered with hemorrhagic clots on the lesser curvature of the prepyloric region of the stomach. Three weeks later, the repeated endoscopy revealed that the ulcer had perforated to duodenal bulb with a so-called double pylorus formation. The endoscopic features taken after two years showed unchanged appearence of the double pylorus still as same as the last one. In our case followed up clinically for two years with the serial endoscopic exminations, it was possible to observe the healing process of prepyloric ulcer with the formation of the antrobulbar fistula and its constant and unchanged features for two years without any complaints.

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A 43-year-old male patient having an episode of reccurent epigastric pain has been treated with a diagnosis of gastric sarcoidosis and followed-up by gastroscopy for 7 years. Initial examinations were done in March 1978. Multiple ulcer scars with converging folds were noted in the f ornix and body on upper GI series. Gastroscopy showed on irregular, nodular mucosa with converging folds in the f ornix, open ulcers and scars in the body. Biopsy specimens taken from the gastric lesions revealed non-necrotizing granulomatous inflammation with giant cells. Laboratoly findings showed negative Kveim test and normal angiotensin converting enzyme. Chest X ray finding was also normal but biopsy specimens taken from bronchial mucosa and scalenoid lymph nodes showed granulomatous inflammation. After administration of steroid, symptoms subsided and gastric ulcer healed. During the past 7 years, gastroscopy were performed on many occasions. At these examinations, new ulcerations were noted on the lesser curvature of the body. Biopsy specimens from the new ulcer margins also showed granulomatous inflammation. The nodular elevated lesion has not changed during the follow-up period. The patient has had no symptoms after administration of steroid but new ulcer and reccurent ulcers developed.

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A 19-years old male was admitted with complaining of hematemesis after taking alchool and repeated vomitting. Endoscopy revealed a small hematoma-like protrusion on the anterior wall of the esophago-cardiac junction, which surface was smooth and purplish red, and the size was 5mm in diameter. As continuous bleeding was observed, 99.5% ethanol was injected to the bleeding site. Hemostasis was achieved satisfactorily. Two days after endoscopic injection, protuburance which looked like a hematoma revealed reddish change at its base, but there was no bleeding at all. As the third examination after three days, revealed an enlargement of hematoma-like protuburance, ethanol was injected again although it did not bleed. Finally endoscopic examination revealed a small white coat without evidence of any elevation. As mentioned above, a very unusual case similar to Mallory-Weiss syndrome was reported.

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Case 1 is a 60-year-old woman who entered our hospital with complaints of hematemesis, melena and epistaxis. She had a long history of recurrent epistaxis but had no external skin and mucosal telangiectatic lesions. The diagnosis of hereditary hemorrhagic telangiectasia was made endoscopically with characteristic multiple gastric telangiectatic lesions. Case 2 is a 54-year-old man who had been under treatment of lumbago and was referred to us for the management of gastrointestinal bleeding and epistaxis. Endoscopically, multiple gastric telangiectatic lesions were found, which were bleeding during endoscopic observation. In both cases, GI bleeding were controlled by the conventional therapy but epistaxis was not. After a few weeks of hormone therapy, epistaxis was decreased in frequency to one third and a half than before respectively. The adverse effects of this therapy were transient breast discomfort in case 1 and painful gynecomastia in case 2, However, these were not so serious as to abandon the therapy. From these experiences, we think that a systemic hormone therapy would be a suitable method of reducing the tendency of epistaxis and probably GI bleeding.

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A 67-year-old male was admitted to our hospital complaining of general malaise and body weight-loss. No abnormal findings were noticed in physical examinations of the patient. However, chemical laboratory tests suggested the presence of biliopancreatic disorders because of the elevation of LAP, GOT and FBS levels in the serum. Abdominal ultrasonography demonstrated a tortuous dilatation of the main pancreatic duct with irregular echo level of the pancreas and with no abnormality of the liver and bile duct system. Endoscopic ultrasonography scanned through the duodenal wall also showed a hypoechoic mass within the dilated main pancreatic duct at the head. ERP revealed a round radiolucent shadow within the duct (15×13 mm in size), suggesting the presence of a tumor of the pancreas at the head. The lesion was directly inspected as a grayish villous tumor within the duct by using peroral pancreatoscopy under duodenoscopic guidance. Direct biopsy from the tumor through the papilla under duodenoscopy showed no malignant development (Group II). Laparotomy with pancreatoduodenectomy was then performed because the lesion could not be completely ruled out from malignancy. Resected specimens revealed a tumor, 20×16×16 mm in size, within the duct at the head of the pancreas, and it was histologically confirmed as a papillary adenoma of the duct with partial atypism.

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Lymphangioma of the gastrointestinal tract is a very rare entity. The current report describes a case of a lymphangioma of the duodenum. A 49-year-old female consulted. our hospital for precise examination of the upper gastrointestinal tract. Upper GI series revealed a large polypoid lesion with very long stalk in the duodenal bulb (Figure 1). Endoscopic Polypectomy was performed and the polyp was succesfully removed. The resected polyp was 70×22×15mm in size (Figure 3), and it was histologically diagnosed as a lymphangioma.

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A 69-year-old man was admitted to our hospital with complaints of right lower abdominal tumor, fever and weight loss. A diagnosis of malignant lymphoma of terminal ileum was made by X-ray, endoscopic examination and direct-vision biopsy of the lesion. It is rare that the case of malignant lymphoma of small intestine is diagnosed histologically before operation.

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In our hospital we experienced one case of mutinous cystadenocarcinoma accompanied with ulcerative colitis. A 53-year-old woman suddenly developed mucous bloody diarrhea several times a day, during her hospital visits for therapy of duodenal ulcer. She was admitted to our hospital for detailed examinations. Barium enema study showed lead-pipe configuration, loss of haustra and small dots of barium in the entire colon, and the distended appendix filling with lots of mucuslike subsances. Endoscopic pictures also showed hyperemic and friable mucosa and the enlarged orifice of the appendix. Ileocolectomy and right oophorectomy were performed. Histological examination showed ulcerative colitis and mucinous cystadenocarcinoma of the appendix with localized pseudomyxoma peritonei. Meastasis of the regional lynph nodes were not identified. From the clinical course and radiological and endoscopic findings of the patient, it was considered that adenocarcinoma of the appendix primarily developed, not connected with ulcerative colitis.

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Usefullness of Celestin dilator for esophageal dilatation was reported in comparison with endoscopic cutting by high frequency current. Esophageal dilatation was performed in 15 patients. The cause of stricture was anastonmotic stricture in 11 cases, irradiation in 2 cases, esophageal injury in one case and postsclerosing therapy for esophageal varices in one case. Several treatments for esophageal dilatation were performed ; Celestin dilator in 9 cases, endoscopic cutting by high frequency current in 9 cases, balloon bougie in 3 cases, operation in one case. Treatment with Celestin dilator was exclusively effective in all cases without any complication. Although re-stricture appeared in 4 cases among them, it was cured by the repeated same technique. Celestin dilator has the advantages of simplicity, speed, and ease of passage and adequate of f et in comparison with endoscopic cutting by high f requcncy current. So, it may be used widely for esophageal dilatation in the future.

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The endoscope which has attained a remarkable development is not only indispensable for diagnosis but also playing important roles in treatments and studies of pathophysiology of the gastrointestinal tract. However, the development has not always been attained smoothly as is seen today but is a result of accumulated efforts exerted by many people involved in it. Attempts to observe rectum and vagina with speculum dates back to Hippocrates' time, but the initial attempt to examine the inside of body with light through a tube which could be the origin of the endoscope was first made by Bozzini in 1795, which was called Lichtleiter. The word `endoscope' was used initially by Desormeaux in 1853. He described the use of a straight tube endoscope for obsrervations of the urinary tract, bladder and rectum. It was Kussmaul who developed this procedure further in 1868 and made observation of the esophagus. He was succeeded in inserting the scope into the stomach but was unable to observe it at all. In 1886, Nitze and Leiter produced a cystoscope with an electric bulb as the light source. Based on this cystoscope, the subse-quent development of gastroscope was attained by Mikulicz, Rosenheim, Kuttner, Elsner, Schindler (1920), Korbsch (1925) et al. And a rigid gastroscope was introduced and put to practical use. Then a flexible gastroscope was completed by Schindler and Wolf (1932). It was used widely in Europe but was not in Japan. On the other hand, it was by Einhorn in 1889 that the conception of a gastrocamera, describing that a miniture camera is directly inserted into the stomach and that gastric mucosa is examined from the pictures taken, first appeared in the literature. However, because of the underdeveloped photography, the conception had never developed into a practical use, and only gastrodiaphany was in use. It was Lange and Meltzing (1898) who performed clinical experiment initially with a trialmanufactured gastrocamera, but this again was left entirely abandoned without practicability due to the underdeveloped photography. A pinhole type stereogastrocamera was developed by Porges and Heilpern in 1929, but the value for its practical use was scarce. In 1950, Uji et al developed a gastrocamera on their own, but the initial medel was extremely imperfect. The gastrocamera suffered frequent disorder and was almost discarded. What required for practical use of a gastrocamera depended entirely upon the energetic study being carried out by 8th laboratory, 1st Department of Internal Medicine, University of Tokyo. Subsequently, many improvements were made on the gastrocamera, and as a result its practical value was widely recognized, for which the gastrocamera has come into wide use and become the instrument indispensable for clinical purposes. Development of the fiberscope was originated from Lamm's experiment in 1930 which proved that a bundle of glass fiber can transmit images. Lamm recommended to Schindler its application to gastroscope, but no further progress was made. A fiberscope of practical value was produced initially byHirschowitz et al in 1957. The subsequent develop-ment of the fiberscope has been remarkable to date and is now at the zenith of prosperity. In connection with the development of the gastrocamera, Japan Gastrocamera Society was established in 1959 and developed into Japan Endoscopy Society in 1961 and finally into Japan Gastroenterological Endoscopy Society. The activities of these societies have given a great deal of contribution to the progress of endoscopy. In addition to the development of instrument itself, the matter particularly emphasized in this lecture is the importance of our positive attitude to make the most of its function, to make the observation with a fresh eye, and to analyze the records of photography repeatedly. The endoscope today is applicable to biopsy, for which it is the fact that easygoing attitude is seen on the part of the examiners. However, no progress is obtained b

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