Findings of pancreatoscopy were reported in several kinds of pancreatic disease and compared with the pathological findings. A thin (3.2 mm in diameter), flexible fiberoptic endoscope with bending system (up 160°c, down 90°c) and an irrigation channel (0.5 mm in diameter) was used in this series. Pocedures of the pancreatoscopy were peroral pancreatoscopy (PPS) in 13 cases, intraoperative pancreatoscopy (TOPS) in 12 cases, pancreatoscopy of the resected specimens in 15 cases. In 10 cases of pancreas cancer (common type), pancreatoscopy revealed rough surface in 90%, reddness in 70%, proliferative changes in 70%, and dilatation of capillary vessels (capillary sign) in 60% at the stenosis of the pancreatic duct. Compared with the pancreatoscopic findings in 9 cases of chronic pancreatitis, the characteristic features of the pancreatoscopy in pancreas cancer were revealed proliferative changes and a capillary sign. Histologically, the proliferative changes were due to the cancer invasion to the pancreatic duct and capillary sign due to the hypervascularity in the pancreatic duct. In 4 cases of pancreas cancer (mucous producing type) and 3 cases of intraductal papilloma of the pancreas, pancreatoscopy showed the characteristic findings ; papillary lesions were observed in the pancreatic duct, looking like "frog's eggs", because they had a reddish center, which was ascertained the tumor vessels on histological examination. In the cases of cancer, papillary tumors were large and various in shape, but in the cases of adenoma, they were small and uniform. Pancreatoscopy (PPS and TOPS) is an useful method for not only the differential diagnosis of the pancreas cancer but also the diagnosis of the cancer extention to the main pancreatic duct.

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Endoscopic ultrasonographic determination of the depth of cancerous invasion in the depressed types of early gastric cancer was studied in comparison to the histological structure of the operative specimen and the endoscopic ultrasonogram of the healing stage of benign gastric ulcer Several changes in ultrasonographic patterns due to complication of ulceration were observed in each gastric layer, especially in the third layer, even when the cancerous invasion was limited to the mucosal layer. The non-specific changes in each gastric layer caused by ulceration were as follows. Indistinct narrowing of the second layer, a fine high echo network in the part of low echo of the third layer, irregular interruption of the high echo of the third layer, and wall thickening of the forth layer mainly in the center of ulceration. On the other hand, a decreased echo level of the first layer, a partial defect of the second layer without indistinct narrowing, or a regional stenosis of the third layer were specifically found in the cancerous invasion. By careful endoscopic ultrasonographic examination of each gastric layer according to the above findings, a more accurate diagnosis of the cancerous invasion may be possible.

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Transcatheter arterial embolization (TAE) therapy was performed for 81 patients with hepatocellular carcinoma associated with esophageal or gastric varices. Four patients manifested variceal bleeding after TAE therapy within 6 days. In 45 cases, comparison of endoscopic findings of before and after TAE therapy was done. Two patients revealed worsening of form of varices after TAE therapy and four showed worsening of red color sign of varices. Both patients with variceal bleeding and worsening of endoscopic finding had either severe liver cirrhosis associated with ascites or advanced hepatocellular carcinoma infiltrating into major portal veins. Thus, in patients with severe cirrhosis or advanced hepatoma, TAE therapy may aggravate esophagogastric varices, so that TAE should be done cautiously in these cases.

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Between 1981 and 1983, 987. radiological studies of the upper gastrointestinal tract and 2, 390 duodenoscopies were performed in our hospital. As a result, 23 patients were diagnosed as having heterotopic gastric mucosa of the duodenum. Histological examination of the biopsy specimens from the duodenal elevations revealed fundic glandular mucosa in 19 patients and pyloric glandular mucosa in 4 patients. Of these, 16 patients had multiple nodules measuring 2 to 5 mm in diameter in the duodenal bulb which appeared flat and irregularly shaped. The remaining 7 patients had smooth, hemispherical polyps measuring 10±7 (M ± SD) mm in diameter in the duodenal bulb. There were no morphological differences between elevations consisting of fundic glandular mucosa and pyloric glandular mucosa. Biopsies taken from the gastroduodenal epithelial border revealed a fundic pattern with glands in all 13 patients with heterotopic fundic mucosa. Furthermore, biopsies of the pyloric and antral mucosa contained parietal cells in 7 of these 13 patients. Gastric secretory function disclosed an increase of MAO in 8 of 15 patients, suggesting that the parietal cells population had increased in these conditions. In our 23 cases, neither ulcerative lesions nor inflammatory lesions existed in the duodenal bulb. These findings indicate that the heterotopic gastric mucosa arose congenitally rather than metaplastically.

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The endoscopic injection sclerotherapy (EIS) on esophageal varices has a question of the continuation of its effect-how long is it effective? We discuss on the cases where we could endoscopically follow for more than six months after EIS. We discuss 33 cases including 22 males and 11 females among 57 cases where EIS was performed. We injected 5% ethanolamine oleate directly into the variceal vessels after Takase, Y et al. The mean follow-up period of these 33 cases was 19.8 months. Either negative redcolor sign or improved form factor was obtained in 31 cases just after EIS. We experienced no case of a death whose direct cause was a variceal hemorrhage. In 17 cases (52%), a clinical and endoscopic smooth course was obtained for about 17 months. The 14 cases were endoscopically worsened and the period between the good condition after EIS and endoscopically proved worsened state was about 12 months. So, we think it important to detect earlier the beginning of the worsening of the varices by performing the endoscopy every four months (at least every six months) and treat them early enough before we see fatal hemorrhage.

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Electronic endoscopy (Welch-Allyn VideoEndoscope system) differs from the fiberoptic endoscope in whether or not it contains a light-sensitive charge coupled device (CCD) attached to the distal tip of the scope. The image detected by the CCD chip is passed in the form of an electronic signal through the endoscope to the video processor for display by the television monitor. Since the image of the electronic endoscope is produced electronically, computer enhancement of the image and computer analysis of mucosal changes become available. We tried the image processing of endoscopic pictures of the stomach through the electronic endoscopy, by the real time color image processor (nexus 6400) and the minicomputer (VAX 11/750) First, differential process of red color image and high frequency enhancement were effective methods for emphasizing the image, and clarifying minute morphological changes on the surface of the gastric mucosa. Furthermore, the image for the differential process of red color image described more fine gastric mucosal patterns in comparison with the image by contrast method using indigocarmine dye solution Second, we tried image analyses with the percentage of RGB intensity, and the computer analysis succeeded to show a RGB intensity curve on the endoscopic pictures. In order to evaluate clinical significance of these results, however, further trials are recommended. In conclusion, we consider that the electronic endoscopy will be useful and effective for more detailed diagnosis of the gastric disorders.

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The accuracy of endoscopic ultrasonography (EUS) was tested in 6 patients with cancer of the papilla of Vater. All 6 cases underwent surgical operation. EUS was inserted smoothly into the duodenum where a tumor of the papilla of Vater was clearly visualized in all patients. EUS has offered informations to assess the tumor size ; the invasion to the duodenal wall, the common bile duct and/or the pancreatic duct. Comparison of these results with those from pathological findings of resected specimens showed good correlation. However, regarding invasion to the pancreas, judgement by means of EUS was not possible in 4 of 6 cases because the pancreas was not welldemarcated from the surrounding fat tissues by means of EUS. EUS was superior to conventional examinations in the diagnosis of cancer of the papilla of Vater, particularly making decisions on the extent of the tumorous invasion.

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299 duodenal ulcer (DU) detected by gastric mass-survey (over 40 years old) were followed up for one year with endoscopic examination every 6 months without any medical treatment. 24.1% of active DU at the initial examination healed spontaneously and 31.8% of sicatrized DU at the initial examination relapsed after one year H2 stage (almost healed) ulcers were very common in mass-survey detected DU. 59.4% of them still stayed in the same ulcer stage after one year and 26.0% of them healed spontaneously, while 16.0% of them aggravated. 6 months follow-up of red and white ulcer scars revealed that a recurrence rate is significantly higher in red scars than white ones. 12 cases, including one overt bleeding case, needed medical treatment because of epigastric pain, but there was no surgical case. These results suggest that DUs in patients over 40 years of age elapse frequently without symptoms or aggravation for long periods and as spontaneous healing is not uncommon, not all the patients need active medical treatment.

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A 60-year-old male had been under medication for his duodenal ulcer for 4 years and examined endoscopically 4 times a year. He visited our clinic this time complaining epigastralgia. Endoscopic examination revealed a nail-size hyperemic lesion 38 cm deep from the incisors. This lesion was not stained by Lugol staining method. Histology of the biopsy specimens taken from this lesion revealed squamous cell carcinoma. Therefore, the intrathoracic esophagus was removed followed by dissection of the lymph nodes. In the resected esophagus, there was found a lesion of superficial flat type, 2.5 by 2.0 cm in size, with unclear margin and slightly uneven mucosal surface. The esophageal mucous membrane of this lesion could not be stained by Lugol staining method. Histological specimens from this lesion demonstrated poorly differentiated squamous cell carcinoma with the intact basement membrane in the epithelial layer. In order to find esophageal cancer in the stage of intraepithelial carcinoma, it is obligatory to carry out screening tests of the upper digestive organs, not only for those who complain swallowing disturbance, but also for those who have other digestive disturbances, even if they fail to complain. And endoscopic examination is the first choice among many screening tests. In addition, endoscopic test using Lugol staining method and brushing cytology with capsule are also valuable in detection of intraepithelial cancer of the esophagus.

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A case of gastric hyperplastic polyposis associated with three early polypoid cancers was described. The patient was a 56-year-old male. He came to our hospital on October 11, 1984. Radiographic and endoscopic examination revealed numerous polypoid lesions in the stomach (Figure 1, 3). Histological examination of endoscopic biopsy from some polyps showed hyperplastic polyps with no evidence of malignancy. Total gastrectomy was performed on January 10, 1985. Macroscopic findings of the resected specimen showed thirty-nine polyps from the upper body to the angular region (Figure 4). They varied in shape from Yamada's classification I to IV and measured 2-20 mm. in diameter. Histologically, all of the polyps were diagnosed as foveolar hyperplastic type except for three polypoid cancers. These cancerous lesions were located on the lesser curvature (12 x 7 mm. in size), the posterior wall (5 x 4 mm.) and the greater curvature (7 x 6 mm.) of the angular region respectively and composed of papillary adenocarcinoma without any metastasis (m, no, ly (-), v (-)) (Figure 5, 6, 7). The three polypoid cancers were not distinguishable from the other hyperplastic polyps endoscopically and it was practically impossible to get biopsy specimens from all of the polyps. Accordingly surgical treatment should be taken into consideration in cases of gastric polyposis such as the one presented here.

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A fifty-three years old woman was admitted to our hospital because of epigastralgia and general fatigue. The laboratory findings including serum immunoelectrophoresis and bone marrow examination were unremarkable except for microcytic hypochromic anemia and positive occult blood test for faces. Chest X-ray film and ECG were also not remarkable. The upper gastrointestinal series showed folds covered with granules on the gastric body. The endoscopic examination showed bleeding tendency on the granular surface of the folds on the gastric body and the antrum. Amyloidosis was diagnosed by the gastric biopsy of the folds. Amyloid deposit was also seen on the colonic and rectal mucosa histopathologically, though barium enema and lower endoscopic examination showed no particular findings. The total gastrectomy was performed for improvement of anemia. Amiloid deposit was seen on the stomach, the gall bladder and the liver. The immunohistochemical examination of amyloid protein by PAP method gave negative result for AA, Ax, AA and pre-albumin. The patient lives well without any complication in one year after surgery.

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Two rare cases of adenosquamous cell carcinoma of the stomach diagnosed by gastroscopic biopsy have been reported. Case 1: A 67-year-old man was admitted to our hospital with complaints of epigastralgia and bloody stool on May 1981. Roentgenographic and endoscopic studies showed Borrmann's type 2 carcinoma at the antrum. Histological examination of the biopsy specimens revealed squamous cell carcinoma and well differentiated adenocarcinoma. Histological findings of the resected specimens of the stomach showed advanced cancer, measuring 4 × 5cm invaded into the serosa (se). No metastatic lesion of the regional lymph nodes was noted. He still lives at five years after surgery. Case 2 : A 72-year-old woman was admitted to our hospital with complaints of epigastric discomfort on May 1982. Studies of upper G. I series showed carcinomas of Borrmann's type 1 and type II a at the antrum. Microscopically, biopsy specimens revealed squamous cell carcinoma and poorly differentiated adenocarcinoma. The histological findings of the resected stomach revealed an early cancer (type I + II a), measeuring 3 × 2.5 cm invaded into the submucosa (sm). However, there was a regional lymph nodes metastasis(n3 +). Surgical treatment resulted in absolutely non-curative operation. She died in 7 months after surgery.

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Two cases of the common bile duct stone were reported. In each case, the stone was removed after being broken by Nd-YAG laser irradiation. Case 1:68-year-old female. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a large stone (33mm by 20mm).in the dilated common bile duct. Endoscopic sphincterotomy (EST) was impossible and percutaneous transhepatic cholangio drainage (PTCD) was performed due to incarceration of the stone in the common bile duct. Cholangioscope was inserted into the common bile duct through PTCD fistula and Nd-YAG laser was irradiated 31 times (1 to 2 secs each time, 30 watts), the tip of the quartz fiber core being contact with the stone. After laser irradiation, the common bile duct stone was broken into ten odd fragments and all these fragments could be extracted through PTCD fistula. These fragments contained more than 98% of cholesterol. Case 2 : 78-year-old male with three stones (max. 25mm × 22mm) in the common bile duct. Removal of the stones was tried using basket catheter after EST. However, the flexure of the common bile duct prevented the basket from opening. Therefore, PTCD was performed and the stones were removed after contact laser irradiation in the same manner as in case 1. These stones contained 55% of bilirubin calcium. It was verified by the above two cases that Nd-YAG laser irradiation, especially contact irradiation, through PTCD fistula is valid as a non-invasive removal of the common bile duct stone, when EST is impossible or gallstones can not be removed by EST alone.Figure 2 Cholangioscopy in case 1. A large gallstone with dark green surface is seen in the common bile duct. The one on the left is the closed-up figure of the right.Figure 3 Cholangioscopy after laser irradiation in case 1. Left : A large gallstone in the common bile duct is broken into fragments. Right : A small fragment is clutched by the basket catheter.Figure 4 Stone fragments extracted through the PTCD fistula. These fragments contained more than 98% of cholesterol.Figure 5 Cholangioscopy after the removal of stone fragments following laser irradiation in case 1. No stone fragment is observed in the common bile duct. Figure 8 Left : A gallstone is in the process of coming out of the orifice performed endoscopic sphincter-otomy (EST). Right : This gallstone contained 55% of bilirubin calcium.Figure 9 Cholangioscopy in case 2. A gallstone is seen in the common bile duct.

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A 76-year-old male visited our hospital for close examination because of abnormal radiological findings pointed out by a mass screening for gastric diseases. An upper GI series and endoscopy revealed a hemispherical elevation indicating a submucosal tumor or extragastric compression. CT scan showed a low density mass retroperitoneally. At surgery, a capsulated retroperitoneal tumor of 3.0 × 3.0 × 2.5 cm in size and 15.5 g in weight was completely removed. Histologic examination revealed a paraganglioma with argyrophil granules. Retroperitoneal paraganglioma was reported only 19 cases in Japan and this was the most smallest case.

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Double pylorus is one of the rare gastrointestinal abnormalities, having a second channel between the antrum of the stomach and the duodenal bulb in addition the true pyloric channel. Only forty-four cases have been reported in the Japanese literature since the first documented case by Matsuki in 1977. We present two cases of double pylorus which seems to be of acquired origin on the occasion of healing process of peptic ulcer Case 1 was a 40-year-old male with complaint of epigastric pain. At the first endoscopic examination, ulcers were recognized on the both sides of the stomach and duodenum. Two months later, as endoscopic examination revealed that gastric ulcer had perforated to duodenal bulb, we confirmed the diagnosis of double pylorus by so-called U-turn technique with endoscopic cannula through the gastroduodenal fistula. Six months later, repeated endoscopic examination revealed that double pylorus had fused and formed a large single pylorus. Case 2 : 73-year-old male who had long history of gastric ulcer disease. By uppergastrointestinal barium-meal examination, a tentative diagnosis of double pylorus was made. At an endoscopic examination, a catheter was inserted into the true pyrolic channel and a dye was injected through the catheter. Then it flew backward to the antrum through the fistula and we confirmed double pylorus.

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Various methods of endoscopic therapy are available today for upper GI bleeding ; however, those for colorectal bleeding have not yet been established. We experienced two cases with persistent rectal bleeding, and could successfully treat them with "Heat Probe method", which was originated by Protell et al (1978). This method has already been evaluated as effective against upper GI bleeding, but has not been used for colorectal bleeding so far. Our experience of these two cases revealed that it is also useful in the treatment of rectal bleeding.

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A case of inverted appendiceal stump removed by endoscopic polypectomy was reported. A 34-year-old male was admitted to our hospital because of intermittent lower abdominal pain. Barium enema examination revealed a semipedunculated, oval polypoid lesion of about 10 × 15 mm with smooth surface in the postero-lateral area of the cecum. Colonoscopy demonstrated a submucosal tumor covered with normal bowel mucosa at the same site in the cecum. Although inverted appendiceal stump was not completely ruled out, a lipoma was strongly suspected because of the location and the character of the polyp. The tumor was removed by endoscopic polypectomy. Histology of the resected polyp confirmed the diagnosis of inverted appendiceal stump.

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A 46-year-old man was admitted in June 1985 because of profuse mucoid rectal discharge and general malaise. Initially, diarrhea occurred once a day four years ago and later, followed by 8-10 bowel movements daily. During the hospitalization, the patient passed much mucus (1300 to 1800 ml per day) per rectum. On digital examination, a soft and non-tender mass was palpable at the tip of the examining finger. Serum Na was 141.6 mEq/L, K 3.3 mEq/L, and C1103.1 mEq/L. Fecal Na was 118.2 mEq/L, K 20.0 mEq/L, and Cl 108.8 mEq/L. Barium enema study revealed a huge tumor with a shaggy nap feature in the rectum. Sigmoidof iberscopy showed a soft mass which had nodularity and mucus on the surface. Histologic finding of the biopsy specimens revealed villous adenoma with severe atypia suggesting malignancy. He underwent Miles operation. In the resected specimen, the huge tumor measuring 17 × 18 × 3.0 cm occupied the entire circumference of the lumen and had a granular surface without ulceration. Histologic finding of the resected specimen showed villous adenoma restricted largely to the mucosa except for a small area of submucosal invasion which revealed well differentiated adenocarcinoma proliferating in a villo-tubular pattern. One of the lymph nodes attached to the rectal wall was involved by the tumor. Postoperatively, the serum potassium returned to normal and the patient made an uneventful recovery.Villous tumor with electrolyte depletion has been rarely reported in Japan.

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