Endoscopic feature of the duodenal papilla has been investigated in case of pancreaticbiliary disease. We have classified endoscopically the minor duodenal papilla into three types ; common, swelling, and solid-swelling type. In 94 cases, 42 cases (44.7%) were common type, 42 cases (44.7%) were swelling type, and 10 cases (10.6%) were solid-swelling type. Common type was seen rarely in cases of chronic pancreatitis or pancreas divisum. However, solid-swelling type was seen in many cases of pancreatic diseases. Therefore, it is suggested that the accessory papilla may be changeable from the common type to the swelling type or solid-swelling type according to the disturbance of pancreatic drainage. It is concluded that we can get some informations about the disturbance of the pancreatic drainage from the endoscopic observation of the minor papilla.

View full abstract

The endoscopic papillotomy of the minor papilla was performed successfully by using a papillotome of needle type (fistulotome) in three cases ; one case of pancreas divisum and two cases of chronic pancreatitis. The new method gave the accurate diagnosis to the case of pancreas divisum by ERCP through the opened minor papilla, and it relieved persistent symptom from two cases of chronic pancreatitis by improvement of pancreatic drainage. No severe complications were experimenced except slight epigastric pain in this series. It is concluded that the endoscopic papillotomy of the minor papilla is useful as a palliation of treatment of chronic pancreatitis and as a diagnostic method of pancreas divisum, failed in accessorius pancreatogram by ERCP. My experience is too small, but the endoscopic treatment to the pancreatic diseases will be tried actively not only through the major papilla but also through the minor papilla in the near future.

View full abstract

As a part of diagnostic trials using EUS in lesions of the upper digestive tract, the capacity of endoscopic ultrasonography (EUS) in determining the depth of cancer invasion was discussed. Eight patients with esophageal cancer and 78 patients with gastric cancer, including 58 with gastric cancer in which histological finding were also obtainable, were examined by EUS. The upper digestive tract was displayed by EUS as a 5-layers structure, namely, the 1st hyperechoic & the 2nd hypoechoic layers containing of mucous, mucosa and mucosal muscle, the 3rd hyperechoic layer as a submucosal layer, the 4th hypoechoic layer as a proper muscular layer and the 5th hyperechoic layer containing of subserosal layer and serosa. Based on the changes in these layers structure on scans, the depth of cancer extension could be determined. In the cancers confined to the mucosa (m cancer), no echographic changes were observed in any layers except the irregularity of the 1st and 2nd layers. In the cancers involving the submucosa (sm cancer), the sm layer was exhibited as a irregular layer without interruption. The cancers extending into the proper muscle layer (pm cancer) produced interruption at the sm layer. Interruption at the 3rd and 5th layers with highlevel echo was observed in the cancers extending into the subserosa or deeper tissues. In the cancers complicated by ulcer, the differentiation between the interruption caused by a tumor and that by an ulcer was possible based on the morphological appearance in the sm layer. That is, an abrupt interruption of the sm layer was caused by a malignant invasion, on the other hand, an ulcerative change showed a tapering interruption of the sm layer. Gastric cancer with scirrhus invasion was presented characteristic images by EUS, namely, swelling and destruction of all layers, especially of the sm layer. Advanced cancers were correctly differentiated from early cancers by the presence of the interruption of the sm layer in 54 of 58 cases (93.1%). Furthermore, a correct distinction of the cancer extending into the m, sm, pm and ss or deeper tissues was made in 33/41 cases (80.5%).Our result showed the usefullness of EUS in determining the depth of cancer invasion.

View full abstract

At first, some special techical points of our endoscopic examination and polypectomy of the colon and rectum were described. Next, a series of 363 polyps endoscopically removed during the period from March 1975 through December 1984 at our department were analysed. The largest number of these polyps was found in the rectosigmoid colon and the most common histologic type was adenoma. So-called cancer in adenoma was found in 31 out of these 363 polyps, or 8.5%. Especially, the frequency of malignant change among polyps 1.0 cm or greater in its largest diameter was 23%. As metachronous development of polyps was frequently found in patients who had two or more polyps at the time of the initial colonoscopic examination, close follow up is mandatory in these patients. Serious complication was not encountered in our series. Now colonoscopic polypectomy is safely performed. We suggest that colonoscopic polypectomy should be recommended as a means of reducing the incidence of colorectal malignancy.

View full abstract

We have used a newly-developed spectrum analysis apparatus to detect and to trace the dynamics of hematoporphyrine derivative (HpD) in the tumor-bearing mouse. Also we have detected the fluorescence of gastric cancer via fiberscope following injection of HpD and evaluated whether the spectrum analysis following injection of HpD can be used to diagnosis gastric cancer. Eighteen gastric cancer-bearing mice were used in the fundamental study. Following intraveneous injection of 20 mg/kg of HpD, measurment of relative concentration of HpD in the normal skin and transplanted tumor area were began. These measurements were performed until 96 hours after injection in order to realize the dynamics of HpD. The measurement of relative concentration of HpD in vivo were performed using optical density method which concerning several apparatus as illustrated in the Figure 1 and 2. An additional experiment using 12 normal nude mice approved that this method could measure exactly the relative concentration of HpD in vivo (Table 1). The relative concentration of HpD in the normal area was significantly higher than that in the tumor area until 15 minutes after injection of HpD. Then, the concentration of HpD in the normal area decreased gradually. while that in the tumor area increased constantly. Finaly, the concentration of HpD in the tumor area showed a significant higher concentration of HpD than normal area since four hours after injection of HpD (Figure 4). Accompanying with the results showed in the Table 2 we considered that HpD had the property of tumor accumulation rather than tumor affinity. Several additional data showed in the Figure 3 and Table 3 suggested that the impaired excretion of binding complex of HpD and serum albumin in the tumor area may be the mechanism of the tumor accumulation of HpD. The fundamental study using gastric cancer-bearing mice suggested that fluorescence spectra analysis following injection of HpD may be used to diagnosis gastric cancer via fiberscope. Based on this result, a 73 years old male suffering from advanced gastric cancer and severe uremia had been tried. Seventy two hours after intraveneous injection of HpD 2.5 mg/kg, photoradiation therapy for cancer were performed. Just before performance of photoradiation therapy, fluorescence spectrum analysis of tumor and normal area were done. The method and apparatus for examination via fiberscope wereillustrated in the Figure Z. The tip of the spectra analyzing fiber was contacted to the surface of gastric mucosa to examine the fluorescence. As the curves showed in the Figure 5 the fluorescence spectrum of the cancer area has a high peak at the 630nm of wavelength. which is quite different from the spectrum of normal area having 580 nm and 600 nm, mainly. The HpD concentration in the cancer area (A-A') was also noted to be higher than that in the normal antrum mucosa (B-B'). In conclusion, this study approved that HpD has the property of tumor accumulation rather than tumor affinity. And the fluorescence spectra analysis of stomach following injection of HpD can be used to diagnosis gastric cancer via endoscopy.

View full abstract

Endoscopic ultrasonography (EUS) have been performed in 15 cases suspected pancreatic cancer. EUS demonstrated pancreatic tumor as a low echoic lesion in 13 cases, and as a low and isoechoic lesion in a case of small pancreatic cancer. EUS also showed clearly the margin and the internal echo of the tumor in this case. In 10 of 14 cases (71%), the margin of pancreatic tumor was irregular, and in 11 cases (78%), the internal echo was even. Moreover, we compared diagnostic accuracy in various diagnostic methods for pancreatic cancer. Pancreatic cancer was correctly diagnosed in 11 of 12 cases (92%) by ERCP, in 9 of 15 cases (60%) by US, in 14 of 15 cases (93%) by EUS and in 8 of 12 cases (67%) by selective angiograhy. Therfore, it is concluded that EUS demonstrates pancreatic cancer as a low echoic lesion with irregular margin and even internal echo, and EUS can be one of the most useful diagnostic methods for pancreatic cancer.

View full abstract

The endoscopic variceal sclerosis (EVS) was employed in 24 patients with esophageal varices. In 15 patients, ethanolamine oleate was injected intravariceally (EAO, emergent : 2, elective : 4, prophylactic : 9). On the other hand, polidocanol was injected extra or intravariceally in another 9 patients (emergent : 0, elective : 4, prophylactic : 5). The effects and complications were compared between these two methods. 1. The mean number of times that sclerotherapy was performed for apparent decreasement of varices and red color sign were 1.5 times with EAO and 2.3 times with polidocanol. Therefore, the intravariceal injection with EAO was much more effective than that with polidocanol. 2. The complications were seen more often in the EVS using EAO than using polidocanol. 3. EAO should be injected intravenouslly by fluoloscopy because extravariceal injection of EAO formed large ulcer. Therefore, EVS using EAO is more complicated than that using polidocanol.

View full abstract

The aim of this study is to report the efficacy and safety of endoscopic photodynamic therapy (PDT) with hematoporphyrin derivatives (HpD) and Argon dye laser for 53 lesions of 50 patients with tumors of the stomach and colon. The effect of PDT was histologically examined in a case of gastric adenoma, 8 cases of early gastric carcinoma, 2 cases of colonic adenoma and a case of colonic carcinoma. In the remaining cases, the local curability was evaluated by a follow-up biopsy. The efficacy of the initial treatment was 88% for 8 cases of gastric adenoma, 67% for 30 cases of early gastric carcinoma, and 43% for 7 therapeutic failure of Nd : YAG laser. After repeated treatment, 77% of the cases of early gastric carcinoma and 71% of the therapeutic failure of Nd : YAG laser are thought to be tumor-free at the present. The efficacy of the initial treatment was 76% for 17 cases of polypoid or protruded type of lesion, in which the depth of tumor invasion of all but one was estimated to be intramucosal, compared with 61% for 28 cases of flat or depressed type of lesion, 11 of which were thought to have submucosal invasion of the tumor. Photodynamic therapy with a power of 300 mW and the approximate total energy delivered per square centimeter of more than 90 joules seems to be effective for superficially invaded tumor, but curative effects can be hardly expected in cases of fungating tumor or tumor invaded through the muscle layer. The effect of the majority of colonic tumors was partial. The technical difficulty of administering sufficient light en-efce was an another cause of incomplete treatment. Improvement of irradiation equipment, such as the one which has a 360 degree divergent angle shown in this report, is necessary to improve the efficacy of PDT. No serious complications of PDT were encountered, but side effects of HpD such as skin rash and dermatitis to be treated were noted in 22% of the cases.

View full abstract

We investigated 29 cases of the biliary tract carcinoma and 19 cases of anomalous arrangement of the pancreaticobiliary duct. As the result, it was found that anomalous arrangement and the biliary tract carcinoma were closely connected with each other, and 8 cases of the biliary tract carcinoma with anomalous arrangement didn't have cystic dilatation of the common bile ducts and included 5 cases of the choledochal carcinoma. From our studies, we suspected that anomalous arrangement of the pancreaticobiliary duct played an important part of the etiology of the biliary tract carcinoma, not only of the gall bladder carcinoma but also of the choledochal carcinoma.

View full abstract

A 76-year-old male was admitted to our hospital complaining of dysphagia. A barium swallow examination of the esophagus showed a smooth surfaced, soft, 2cm-sized protruded lesion in the upper portion of the esophagus (Figure 1). Esophagoscopy with a fiberoptic endoscope revealed a blue-red colored, pedunculated submucosal tumor 20cm from the incisers (Figure 3 and 4). When pushed with biopsy forceps, the tumor easily indented, suggesting a vascular lesion. Dynamic CT scan with bolus infusion of contrast medium also suggested a vascular tumor in the esophagus (Figure 6). Endoscopic polypectomy was successfully performed following injection of 3.4 ml of ethanol into the stalk of the tumor in order to prevent massive bleeding. No bleeding was observed and the excised specimen measured 2.2× 1.2 × 0.9 cm (Figure 9 and 10). Histologically, the tumor was a capillary hemangioma, which is very rare (Figure 11). Twenty-five cases of esophageal hemangioma have so far been reported in Japan and endoscopic polypectomy was performed in only 4 (including our case) of 25 cases.

View full abstract

We have presented two cases of Barrett's ulcer. Case 1 was a 69 years old man who was admitted because of palpitation. Radiological and endoscopical findings showed a huge ulcer in the lower esophagus. Case 2 was a 70 years old man who was admitted complaining oppression on the chest. Radiological findings showed a partial stricture of the lower esophagus and some barium spots on the proximal mucosa from the stricture. A map-like ulcer in the oral site from the stricture and a shallow ulcer in it were revealed by the esophagoscopy. Specialized columnar epithelia were found on the biopsied specimens from the background mucosa of both cases. These results suggested that the pathogenesis of our cases could be of acquired. Pirenzepine, sucralfate and cetraxate were administered for the treatment of each cases. Following this treatment, ulcers of both cases were cured without any complication. We would conclude the antacid and mucosal defensive agent were effective for the treatment of Barrett's ulcer.

View full abstract

A case of esophageal cancer of peduncular polypoid lesion was reported. A 75-yearold male patient was pointed out a polypoid lesion in the esophagus at routine upper gastrointestinal series. He was admitted to Mie University Hospital for further examination and treatment of the esophagus. The physical examination and blood chemistry were almost within normal limits. CT-scanning of the abdomen and mediastinum was negative. Panendoscopic examination showed a polypoid lesion with fine granular surface of lcm in diameter at the 33cm distal from the incisors, yet the mucosa around the tumor seemed to be intact. Endoscopic polypectomy was performed. The resected specimen was a nonkeratinized, well differentiated squamous cell carcinoma in the mucosal epithelium without invasion to blood nor lymph vessels. Generally, esophageal cancer is grossly classified into three types, protruted, superficial, and ulcerative type. However, among the protruded type, peduncular polypoid esophageal cancer is very rare. After the endoscopic polypectomy, primary curative dose of irradiation therapy was done. Therefore it seemed likely that the prognosis of this case might be good.

View full abstract

Esophagography revealed a tumorous lesion in a 72-year-old woman. Endoscopy was performed with or with out dye staining 29 cm below the upper incisor teeth and the following three findings were obtained : (1) The mucosa extending toward the cardia had already become reddish with a relatively welldefined margin ; it turned blackish brown after the scattering of Congo red, while it remained unchanged after reaction with Lugol's solution. (2) The mucosa extending oral reacted only with Lugol's solution. (Based on the above two findings, the case was diagnosed as Barrett's esophagus with no hiatal hernia.) (3) A superficial elevated lesion was found in the mucosa extending toward the cardia ; it did not react with the two dyes. The lesion was identified as adenocarcinoma based on biopsy. The patient underwent subtotal esophagectomy and retrosternal esophagogastrostomy. Gross observations of the resected organ revealed that the esophagogastric junction was irregular, and that a protruded tumor (2 × 2 cm) was present in the mucosa extending toward the cardia. The tumor was histopathologically classified as well-differentiated adenocarcinoma which invaded the submucosa and metastasized to an adjacent lymph node. Barrett's esophagus was microscopically shown to have (a) a mixture of fundic-, intestinal- and junctional-type epithelia, (b) esophageal glands in the submucosa, and (c) squamous epithelia like islets in the columnar epithelium. These three histopathological findings suggested that Barrett's esophagus in the patient might be of the acquired type.

View full abstract

We have experienced a very rare case where we could observe the growing processes of 10 gastric polyps endoscopically. A gastic polyp, on a mass survey of 10 years ago, was found in a 49-year-old female patient. Four years later, as the polyp grew into Yamada's type IV from type III and the head grew larger, we polypectomized the polyp. During the follow-up study for over 5 years after the first polypectomy, we could observe the growing processes of the 9 gastric polyps endoscopically. Almost all the polyps pursued the growing processes from so called polypous bud to Yamada's type I, II, III and IV polyp successively. Four of 9 polyps were polypectomized later. The mean growing time of 4 polyps in which we could observe the growing process from polypous buds to Yamada's type IV polyps was 2 years and 7 months. Furthermore, there remained in this stomach more than 10 small, flat and red spots that we thought were the predecessor of polypous bud. As to which of these many spots will increase in growth and with what momentum and how long it will take to grow into polypous buds are still unkown.

View full abstract

An uncommon case of diffuse infiltrative cavernous hemangioma of the stomach diagnosed by gastroscopy and upper gastrointestinal series is presented. The patient was an 18-year-old woman, her complaints being nausea and vomiting followed by massive hematemesis. She had hematemesis at the ages of 8 and 15. Gastroscopy revealed marked thickening and tortousity of mucosal folds which were bluish in color in the greater curvature of the gastric body, together with retention of large amounts of blood in the stomach. Upper gastrointestinal series again disclosed many thick and tortous mucosal folds in the gastric body, reminding us of Menetrier's disease or malignant lymphoma. Abdominal angiogram revealed a thickened wall of the gastric body, but there was neither evidence of aneurysm nor abnormal tumor stain. The gastric body was partially resected together with the greater omentum. At surgery there were many tortous and dilated blood vessels in the serosal surface of the stomach and omentum. Microscopically, there were many dilated blood vessels filled with blood and lined by a single layer of endothelial cells, occupying the whole thickness of the gastric wall with the main location of the submucosa. No return of bleeding occured during the 20 months followed up.

View full abstract

A 48-year-old woman was admitted to our hospital complaining of abdominal pain and diarrhea. On physical examination, abdominal mass and tenderness were present in the right hypochondric region. An upper gastrointestinal series disclosed an internal fistula in the greater curvature of the antrum and longitudinal ulcers in the terminal ileum. A barium enema confirmed the presence of a gastrocolic fistula between the greater curvature of the antrum and the transverse colon. Barium enema and colonof iberscopic findings showed cobblestone-like appearances, longitudinal ulcers and apthoid ulcers in the transverse colon and the sigmoid colon. Total colectomy and ileectomy were performed. The greater curvature of the antrum was adherent to the transverse colon. The wall of the ileum and the colon were edematous and thick with the longitudinal ulcers and cobblestone-like apperances. On microscopic findings, fissures, transmural inflammation and granulomas were noted. Fistula formation (perianal, enteroenteric or enterocutaneous) is well recognized in Crohn's disease. Gastrocolic fistula, however, are uncommon with only two patients except our case in Japan and thirteen patients in other countiries having been reported upon in the literature. This report describes a case of Crohn's disease with gastrocolic fistula.

View full abstract

A 60-year-old man with liver cirrhosis was admitted to our emergency unit because of epigastric pain, melena and purpura. By emergency endoscopy, shallow ulceration was found in the antrum and diffuse submucosal hemorrhage from the upper body down to the duodenal bulb. By colonoscopic examination, hemorrhagic lesions were also observed in the large bowel. Ig-A depositions were detected in the capillary wall of the stomach, duodenum and colon by immunohistochemical study of the biopsy specimens . Aiagnosis of Schoenlein Henoch Purpura was consequently made. On the basis of hospitalization with prednisolone administration and plasmapheresis, clinical manifestations and endoscopic findings were improved in four months. The immunohistochemical study of the biopsy specimens was useful to distinguish the intestinal mucosal lesions with Schoenlein Henoch Purpura from those with chronic liver disease .

View full abstract

Four cases of Exulceratio simplex (Dieulaf oy's ulcer) treated with urgent endoscopic hemostasis were reported. From april 1980 till august 1984, 202 consecutive patients with massive upper G-I-tract bleeding were treated at our hospital. During the same period, we encountered four patients with Exulceratio simplex (Dieulafoy's ulcer). All patients were male whose ages ranged from 57 to 77 years with an average age of 65.3 years. Urgent fiberoptic endoscopy revealed a solitary mucosal defect which was 2-3 millimeters in size with an exposed vessel at the ulcer base in all patients. Endoscopic hemostasis was carried out in four patients. In one case, complete hemostasis was obtained with local injection of Hypertonic Saline-Epinephrine (HS-E) solution alone. In the other two cases, complete hemostasis was obtained with the combination of local injection of HS-E solution and high frequency electric coagulation procedure. Following initial treatment with combination of local injection of HS-E solution and high frequency electric coagulation, emergency operation was required because of massive re-bleeding in the last one case. These endoscopic procedures are worth trying in hemostasis of the cases with Exulceratio simplex (Dieulafoy's ulcer).

View full abstract

A 59-year-old woman with a paroxysmal episode of severe watery diarrhea, caused by a vasoactive intestinal polypeptide (VIP) secreting tumor of the pancreas with liver metastasis, is described. Plasma concentration of vasoactive intestinal polypeptide, pancreatic polypeptide, calcitonin and somatostatin was all elevated, 2, 700 pg/ml, 620 pg/ml, 5, 000 pg/ml, 6, 400 pg/ml, respectively. The primary tumor of the pancreas contained VIP, pancreatic polypeptide, C-peptide, somatostatin, calcitonin and metastatic lesions of the liver contained VIP, glucagon and somatostatin as demonstrated by radioimmunoassay of these hormones in the tumor tissues and immunohistochemical studies. The serum level of these hormones, especially VIP, was very labile. It should be suggested that lability of the serum VIP level is the most causative factor for the paroxysmal phenomena of the clinical symptoms.

View full abstract

Six cases of antibiotic-associated colitis, one of pseudomembranous colitis (PMC) and 5 of acute hemorrhagic colitis (AHC), were observed from March 1982 to February 1983. The age range was from 13 to 58 years (mean 38.2) and sex ratio was 2 to 1 with male preponderance. Antibacterial agents used were amoxicillin (3 cases), ampicillin, cefotiam and combination of cef oxitin and cef actor. These drugs were prescribed for cystitis, pneumonia, common cold, tonsillitis and prophylaxis (2 cases). Main symptoms were diarrhea, abdominal pain and bloody stool. The diarrhea appeared 10.7±6.3 days (range 4-23) after the initiation of antibiotic therapy. Clostridium difficile was detected in stool specimen from PMC and Klebsiella oxytoca from 2 of 5 AHC. Endoscopically, there were yellowish-white, plaque-like lesions with intervening areas of edematous mucosa in the cecum and ascending colon of PMC and the mucosal redness, edema, erosion and bleeding mainly in the rectum and sigmoid colon of 5 AHC cases. All of the patients were completely cured with cessetion of the antibiotics by 6.2 ± 3.7 days (range 3-14). Colonoscopy was a useful procedure for diagnosis of the antibiotic associated colitis and early withdrawal of causative agents led to prompt subsidence.

View full abstract

We report on 53 endoscopic investigations (in 43 cases for gastroduodenoscopy and 10 cases for colonoscopy), using a new type of electronic endoscope which has no glassf fiber bundle for imaging. Findings of these examinations were shown in Table 2 and Table 3. This system is composed of 3 devices (Figure 1). Pictures of digestive tract are caught by image sensor at the distal tip of the endoscope, then transported to the processor in which the signals are transformed to be visualized, and finally displayed on TV monitor. Characteristics of the three types of the scopes were shown in Table 1. To evaluate the maneuverability of the gastroduodenoscope, the mucosal surface of the stomach and duodenal bulbus was divided into 25 areas and the easiness of visualization in each area was investigated. As the results shown in Table 4, some problems were noticed to manipulate this scope, especially to observe the cardia and the anterior wall of upper gastric body. In case of total colonoscopy, the caecum was able to be observed in half of 6 patients. However, 2 of the 6 patients had marked intestinal adhesion from previous surgical treatments, and these patients were thought to be impossible to observe the caecum using recent f iberscope. Therefore, ultimate insertion ratio into the caecum became 75% except for these 2 cases. The quality of the television images of the upper and lower digestive tracts was excellent. Pictures obtained in this study were shown in Figure 2 to Figure 7. Furthermore, as many people can observe pictures of digestive tracts through the examination at the same time by TV monitor, this videoendoscope system was useful for teaching purpose. As the results, this endoscope system was thought to be acceptable for daily gastro-intestinal examination.

View full abstract

The authors analysed the results of endoscopic examinations of the small intestine in 4043 patients. This study was undertaken to evaluate the effectiveness of different methods of endoscopy of the small intestine. It has been established that on the given stage only transanal ileoscopy and peroral jejunoscopy may be recommended to the widely practice as a most informative and safe methods.

View full abstract