The clinical evaluation of endoscopic ultrasonography (EUS) in the diagnosis of submucosal tumor (SMT) in the upper digestive tract is discussed in this paper. EUS was carried out in 45 patients with submucosal tumor and 31 patients with submucosal tumorous lesion compressed by extracanal organs. The differential diagnosis between SMT and tumorous compression was accomplished without error using this method. All the cases of submucosal tumors were easily detected, even if their size was smaller than 5 mm in diameter. Furthermore, it was possible to detect which layer had SMT in the 5 layer structure of the digestive tract wall revealed by ultrasound, and the size of SMT shown by EUS was in good correspondence with the resected material. The diagnosis of leiomyoma and/or leiomyosarcoma was determined by detecting the origin in the mucosal muscle layer or the proper muscle layer ; however, it was hard to make a distinction between these two diseases through EUS findings. Differential diagnosis of SMT in the submucosal layer was possible by analysing echogenicity and echo pattern. A cyst with a hypoechoic mass, an aberrant pancreas with echogenicity intermediate between the echo-level of the sm layer and that of the pm layer, and a lipoma with a hyperechoic mass were detectable by EUS ultrasonogram. The extracanal compressions by other organs and lesions were also shown by EUS. Thus, the ability to delineate the submucosal tumors by using echo-endoscope was evaluated as the most useful method among the conventional body-imaging diagnostics.

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To delineate stomach-pancreas interactions as related to the pathogenesis of duodenal ulcer, comparison of gastric secretory function and exocrine pancreatic function was made in controls, patients with gastric ulcer and those with duodenal ulcer. Gastric juice was aspirated before and after AOC-tetra-gastrin injection (4 jig/kg of body weight). Exocrine pancreatic function was examined by endoscopic pure pancreatic juice collection after instillation of hydrochloric acid into the duodenum (0.1 N, 100ml) ; initial HCO3 concentra-tion (wash-out phase), HCO^-₃ output and maximal HCO^-₃ concentration were evaluated. Serum secretin was also serially measured. Patients with duodenal ulcer showed significantly higher gastric acid secretion. They also showed significantly higher pancreatic HCO^-₃ output as well as higher initial HCO^-₃ concentration as was the case with our previous report on exogenous secretin stimulation. A significant correlationship was noted between gastric acid secretion and pancreatic HCO^-₃ secretion. However, serum secretin response showed no significant difference among the three groups. These results indicate that patients with duodenal ulcer display normal secretin release response and augmented bicarbonate secretion in response to the released secretin. Thus decreased secretin release and subsequently decreased bicarbonate secretion are unlikely causes of duodenal ulcer. Further studies are in progress with acid stimulation of more physiological ranges.

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We experienced good imaged ERP of 1951 cases during the last 10 years. Among them, 15 cases (0.77%) were confirmed pancreas divisum (definitive diagnosed group of 6 cases and probable diagnosed group of 9 cases). Abnormal changes were found at 5 among 6 cases (83%) which could obtain a dorsal pancreatogram and it was rather higher frequency than in other reports. In our cases, the sex ratio was 13:2 and male cases was unexpectedly predominant. About 10 cases with clear alcohol history, we divided alcohol group from non-alcohol group. Analysis was made on chief complaint, pancreatic function, complica-tion of pancreatic disorders and elevation of several pancreatic enzymes. The definitive diagnosis ratio of alcohol group was 67% and that of non-alcohol group was 25%. Studies were also made both to definitive diagnosed group, and to probable diagnosed group and also to total cases. As far as chief complaint is concerned, there was no difference among 2 groups and was found pancreatitis like symptoms in almost all cases. On the other hand, there tended to be abnormal pancreatic function in alcohol group. And also, it tended to be found many complication of pancreatic disorders in alcohol group. In our cases, elevation of pancreatic exzymes were found only in alcohol group and if it would be limited to elevation of only serum amylase, the rate was 50%. Four among 5 cases with dorsal pancreatic disease were alcohol group and they had definitive findings in ERP. Three among them were chronic dorsal pancreatitis and another one was dorsal pancreatic cancer.

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73 cases of drug induced colitis developing after administration of antibiotics were studied on thier clinical symptoms, endoscopic findings, and characteristic changes of mucin in thier colonic mucosa. The results were as the followings. 1. This disease was more frequently seen in female and in relatively young people. 2. Most of administered antibiotics were synthetic penicillins, espcially ABPC and AMPC. 3. Lesions were mainly located in the transverse and descending colon. Endoscopic findings consisted mainly of reddness, edema, and erosions of colonic mucosa. Furthermore, longitudinal ulcers were sometimes seen in the colonic mucosa. 4. The average interval from administration of antibiotics to development of subjective symptoms was 6.5 days. Bloody diarrhea developed in all cases. Subjective symptoms were relieved in 4 days on the average after symptomatic therapy. 5. Microbiological examination of the stools revealed K. oxytoca in 28 cases (42%) and C. difficile in only one case. 6. The mucin character in diseased colonic mucosa showed predominance of sialomucin. On the other hand, the mucin character in healed and normal colonic mucosa showed predominance of sulphomucin.

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Among 6, 854 cases on which gastroscopy had been performed in our institute from Mar. 1982 to Feb. 1985, 52 cases (0.8%) with acute gastric mucosal lesion (AGML) or acute gastric lesoion (AGL) occuring after endoscopy were observed. From 3 to 10 days after endoscopic observation, AGML or AGL occured in these 52 cases. GF-B₃ or GIF-P₃ (Olympus) was used in endoscopic examination. Injection of anticholinergic agent and anesthesia of pharinx were carried out as premedication of endoscopy. In addition, proteinase was administrated orally before the examination in order to eliminate the mucus in the stomach. Average time of endoscopic observation was about 5 or 6 minutes. It is considered that AG(M)L was caused by drinking alcohol in 25 cases (45%), and by mental or physical stress in 11 cases (21%). In the other 14 cases, definite cause was not recognized. But, gastric erosion or superficial gastritis was observed at the initial endoscopy in 10 of these 14 cases. It should be considered that these lesions were aggravated by the endoscopic examination.

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The risk of variceal bleeding after endoscopic sclerotherapy was analyzed with Kaplan & Meier's method and Nelson's method in 25 patients. After endoscopic sclerotherapy, the cumulative bleeding rate increased rapidly in the first 10 days, and thereafter it increased slowly and linealy by 15% per year. The cumulative hazard value is also biphasic and the cumulative hazard in the late phase is compatible with exponential distribution. These results showed that the development of the best procedure of sclerotherapy is needed to lower the bleeding rate in the early phase and that the good control of the liver diseases is also needed to lower the bleeding rate in the late phase. Moreover, these analyzing methods could elucidate the precise effect of sclerotherapy for esophageal varices.

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The prototypes of TV-Endoscope, TV-Gastroscope and TV-Colonoscope were developed for the first time in Japan by Machida-Toshiba. An optical fiber bundle is replaced with CCD (Charge-Coupled Device). The image of light signal focussed by object lens is transformed into electric signal by CCD, and then transmitted to a video processor for display on TV monitors. The prototype TV-Gastroscope was clinically tested in 50 cases with various diseases of the upper G·I tracts, and the prototype TV-Colonoscope in 10 cases with colonic diseases, respectively. The efficiencies of mechanical functions of the instruments such as introduction and manipulation for observation, biopsy and other surgical treatment were evaluated no less better than those of conventional fiberscopes, although there remained some points to be improved. The television image and the still picture were both excellent with high resolution. The present prototypes were totally judged to be practical and acceptable for the routine and precise endoscopic examinations, and the CCD system had an unchallenged advantage over glass fiber in respect to TV electronics, which will soon develope unique optional aspects such as image processing, image filing system and so on.

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During the past fourteen years, we have experienced 52 cases of benign esophageal ulcer among 1403 cases of routine esophageal endoscopic examination. The following results were obtained : 1) These were frequently found in male, and the peak age ranged 60 to 69 years. 2) Clinically, heart burn was the most frequent symptom. In some cases we found hematemesis and melena. 3) Among the 52 cases, 18 were cases with chronic intractable esophageal ulcers endoscopically followed up over 6 months. Hiatal hernia was observed in all the 18 cases and the degree of hiatal hernia tended to well correlate with the severity of diseases. 4) Histopathologically, Barrett's ulcer and dysplasia were observed in some followed up cases, but no malignant change was observed. 5) Thirty-eight out of the 52 cases, especially almost all cases with chronic ulcers had certain associated diseases. Progressive systemic sclerosis and liver diseases were seen in high incidence. Diabetes mellitus, cholelithiasis, coronary insufficiency and bronchial diseases were also frequently encountered in patients with esophageal ulcer. 6) The findings that analysis of gastric juice did not show increased acidity in these chronic cases, and that the drugs which have antisecretory effect of gastric acid output were not so effective suggest the possibility that the disturbance of microcirculation or motor function resulting in the decreased defense mechanism of esophageal mucosa caused by the associated diseases may also play a role in the pathophysiology of esophageal ulcer.

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We studied the accuracy of endoscopic differentiation on 300 lesions between early and advanced cancer prior to surgery. The depth of invasion of these lesions were determined by histological examination following gastrectomy, during the 5 year period from 1979 to 1983. The depth of invasion, i, e. early cancer or advanced cancer, was correctly diagnosed in 83.7% of all lesions studied. As regards the misdiagnoses, 26.0% of m cancer and 48.5% of sm cancer were incorrectly diagnosed as advanced cancer, and 21.4% of pm cancer was incorrectly diagnosed as early cancer. Early cancer was more often diagnosed as advanced cancer, than vice-versa. 40.7% of what was diagnosed by endoscopy as advanced cancer similar to early cancer, was in fact early cancer ; and all of the advanced cancer incorrectly diagnosed as early cancer, was classified as type IIc or type IIc+III cancer by endoscopic observation. Histological examination of excised stomach tissue showed that the accuracy of determining depth of invasion by endoscopy was lowest in the case of signet-ring cell carcinoma (74.1%), and rather low for well-differentiated tubular adenocarcinoma (80.0%). Compared to the accuracy of diagnosis for female cases (88.8%), the accuracy for males was lower (80.8%). A low accuracy was obtained for patients under 39 years of age. In the classification C/M/A, the accuracy for cancer in location M was low (76.3%), as was the accuracy for anterior wall cancer (75.6%). As to the size of lesions, the accuracy for large early cancers, and for advanced cancers smaller than 2 cm in diameter, was approximately 50%, or low. Thus, although routine endoscopic observations have become very sophisticated in recent years, many problems still remain concerning accuracy with which they can determine the depth of invasions, In this connection, we have submitted some examples of cases where direct spraying with indigocarmine has been useful. We believe that dyespraying endoscopic observation, by emphasizing the variation of from and color in gastric carcinoma, will be able to improve the accuracy of endoscopic differentiation between early cancer and advanced cancer.

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Exploratory use of "TV-Endoscope" as the laparoscopy, which was manufactured co-operatively by Machida Co. and Toshiba Medical Co., was reported. This new type of endoscope has an electronic charge-coupled device sensor instead of fiberoptic bundle for imaging. Therefore, the image is clearly visualized on a television monitor, . In the case of fatty liver, the image taken by this new apparatus was stereographic. Because, so-called yellow marking due to fatty deopsit in the hepatocytes protruded slightly from the liver surface. Such finding was never observed by ordinary laparoscopy. Furthermore, this new type of endoscope was easy to handle as a laparoscope, as compared with ordinary one. In conclusion, a further development of "TV-Laparoscope" will be strongly expected. If it is possible to manufacture it, "TV-Laparoscope" may open other possibilities such as computer enhancement of the image or computer analysis of the colour which has been argued very much among the laparoscopists.

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Recently TV-Endoscope was developed by Machida-Toshiba for the first time in Japan. We tried to use this TV-Endoscope for peritoneoscopy, designing a special trocar, and TV-Peritoneoscopy with a prototype of TV-Endoscope (TV-Gastroscope) was evaluated to be clinically acceptable, although there still existed some respects to be improved. TV-Peritoneoscopy is performed by reference to the television monitor, which can be recorded in a video tape or can be f reezed arbitrarily for taking a still picture. The television image and also still picture are definitely superior in quality to those produced by attaching a video camera to a conventional rigid peritoneoscope. It is strongly convinced that the TV-Peritoneoscope system will be the most efficient procedure for peritoneoscope, furnishing unique diagnostic information possibly induced from highly developed electronic manipulations such as image processing or computer analysis as well as image filling system.

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Laparoscopy was carried out four times in three histologically proved cases of primary biliary cirrhosis after intravenous administration of indocyanine green. Case 1(Scheuer's classification stage 1), a 36-year-old female, had enlargement of both lobes, reddish markings, and lymphovesicles. Piecemeal necrosis was observed histologically in some areas. Case 2 (Scheuer's classification stage II & I), a 56-year-old female, underwent laparoscopic examination for the first time two years ago. At that time she had enlargement of both lobes and locally conspicuous superficial vessels with gentle undulation of the left liver surface. These findings became more conspccous at the second examination. Indocyanine green uptake was different from place to place. Case 3 (Scheuer's classification stage IV), a 49-year-old female, had enlargement of both lobes. The liver was brown in color, and the liver surface showed scattered yellow nodules and dark green patches. Very conspicuous superficial vessels and lymphovesicles were also observed. Following indycyanine green administration, the uptake differed from nodules to nodules. These findings seem to be significant for understanding the pathology of primary biliarv cirrhosis.

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A 33-year-old male with a chief complaint of epigastralgia was reffered to Saiseikai Hospital with a suspicion of malignant tumor of the stomach. Gastrointestinal x-ray examination showed narrowing of the antrum, which was irregular in contour. On endoscopic examination multiple huge shallow ulcers that bled easily were seen in the antrum and above the minor curvature of the angulus. The impression given was that of malignancy of the stomach, most probably stage IIc-like advanced carcinoma or malignant lymphoma. Since biopsy specimens were negative for malignancy and TPHA test was strongly positive, anti-leuetic therapy was started, with resultant benif icial effect. Although gastric syphilis is rare, gastric syphilis associated with skin lesions has been reported in recent years. If large, serpiginous, shallow ulcerations are present in the antrum and if biopsy specimens are negative for malignancy and skin lesions are seen, gastric syphilis should be suspected, and serological testing should be carried out.

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A case of elevated lesion surrounded by linear ulcer scar is reported. A 77-year-old woman was admitted to our hospital because of epigastralgia on Dec 2 in 1983. Upper GI series revealed two polypoid lesions with fold convergency at the greater curvature opposite to the gastric angle. Endoscopic examination a week after the upper GI series revealed one polypoid lesion at the angle, but the other disappeared. The polypoid lesion at the angle was Yamada III type, and it was suspected I type early gastric cancer because the polyp was 1.5×2.0 cm in size and its surface was erosive. Operation was performed though the specimens of biopsy showed no malignancy. Histopathologically the elevated lesion was formed with submucosal edema and fibrosis, surrounded by a Ul-IV ulcer scar. Elevated lesion surrounded by ulcer scar as large as in our case is rare and difficult to be differentiated from cancer.

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We reported a case of gastric anisakiasis taking the course of so-called vanishing tumor of the stomach. The case was a 59-year-old male, who complained of epigastralgia 6 hours after eating Sashimi of Coryhaena hippurus. The first endoscopy taken on Sept. 4, 1984 revealed a big and soft elevated lesion that looked like a top shell at the fornix. At the second endoscopic examination taken 7 days after, the elevated lesion disappeared completely and interestingly an anisakis stung in the same site. We reviewed the relationship between the vanishing tumor of the stomach and the gastric anisakiasis reported in the literature in Japan. As the result, our case was one of the rare case as the vanishing tumor of the stomach that was caused by an anisakis.

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We report a case of Menetrier's disease who has an onset in these six years and who showed a specific finding on ultrasonography and CT scan. This 66-year-old female patient was admitted to Iwakuni National Hospital because of meteorism and edema. An upper G. I. series performed six years ago revealed no abnormalities. She had neck lymphadenitis in 1935 and eosinophilia in 1979. The laboratory studies on admission showed a low serum total protein level (3.6g/dl). Protein loss into the G. I. tract was confirmed by the tests of ¹³¹I-RISA and ¹²⁵I-PVP. Gastric juice revealed hypoacidity and serum gastrin level was elevated. Huge, convoluted giant gastric rugae were demonstrated by upper G.I. series and endoscopic examination. The histology of the biopsied gastric mucosa disclosed hypertrophy of the mucosal epithelium and the lamina propria mucosae. On electron microscopic studies, a leak of body fluid from exfoliated mucosal epithelium was found, although the tight junction was normal. Giant rugae, projecting into the gastric lumen were detected by ultrasonography and CT scan. She was treated with oral cimetidine 800mg/day and the serum protein was elevated to 5.7g/dl, and she is still under this medical therapy.

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A 57-year-old woman was admitted to our hospital with a complaint of left upper abdominal pain. Serum amylase, lipase and elastase 1 were elevated. Endoscopic retrograde pancreatography revealed a localized stenosis of the main pancreatic duct in the tail with slightly dilated distal pancreatic duct. Distal pancreatectomy was performed because we could not exclude a pancreatic cancer. In the resected specimen 3 fluke worms, Eurytrema pancreaticum, were found in the main pancreatic duct. Eggs of E. pancreaticum were also found in the fecal sample of a cow raised by the patient's family.

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A rare case of gastric hemorrhage associated with pancreatitis occurring in gastric aberrant pancreas tissue is reported. The patient was a 35-year-old man with a history of heavy intake of alcohol. He was referred to hospital because of vomiting, epigastric pain and tarry stool. Emergent endoscopic examination revealed a 4 cm hemispheric, sub-mucosal mass with ulceration of overlying mucosa and hemorrhage located on the greater curvature of the gastric antrum. The urine amylase was moderately elevated, although the serum amylase was normal range. Upper gastrointestinal radiography revealed a 4×3 cm submucosal, sessile mass on the greater curvature of the gastric antrum. Following endoscopic examination 1 month after the first endoscopy revealed a 1.5 cm cylindrical nipplelike submucosal projection. The tumor became smaller. The ulcer and hemorrhage were disappeared. Partial gastrectomy was performed for the prevention of the relapse due to heavy drinking of alcohol. The pathological findings showed aberrant pancreas tissue in the gastric muscular layer and heaped-up mucosa with a central depression.

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Periportal reddish markings are star-like or net-like in form and frequently observed in patients with chronic active hepatitis, type B, and were histologically revealed to be compatible with piecemeal or bridging necrosis of the hepatic parenchymal cells, especially with sublobular hepatic necrosis. We experienced two different forms of reddish makings (RM) in a case with acute Non-A, Non-B hepatitis and two cases with autoimmune hepatitis on routine peritoneoscopic examination, RM in acute Non-A, Non-B hepatitis case being centrilobular and RM in autoimmune hepatitis cases being multilobular. Histological findings revealed that centrilobular RM implied centrilobular hepatic cell necrosis and multilobular RM implied lobular sized hepatic cell necrosis and of the combination of the two types of RM was caused by massive necrosis on the area.

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We experienced a case of Schistosomiasis, diagnosis being confirmed by aimed liver biopsy under visual control in conjunction with peritoneoscopy. A 59 year-old male with general malaise and loss of appetite more than 5 years prior to the first visit to a doctor who transfered him to our clinic on May 24, 1984 because of mild elevation of γ-GTP activity and abnormal findings suggestive of hepatocellular carcinoma in echogram. He had been in Shanghai, China and Kurume, Fukuoka prefecture, where Schistosomiasis had been prevalent. Liver was 3fb palpable on the right midclavicular line, of which surface being smooth. No other abnormal findings was found in physical examination. Laboratory data on admission were all within normal limits. Echogram demonstrated net work pattern. Abdominal CT showed spotted high density pattern. Peritoneoscopic examination of the liver revealed that liver surface was slightly uneven (Code No. 320 according to Shimada's code number system), and yellowish-whitish egg nodules were scattered on the liver surface. Egg nodules were located in portal area, hepatic parenchymal region, and also in the whitish area. Schistosomal ova with mild inflamatory cell infiltration and fibrosis were disclosed by histological examination of the specimen obtained by aimed biopsy of the liver. It is concluded that peritoneoscopic observation is useful for diagnosis of Schistosomiasis and use of magnified lens and aimed biopsy are indispensable diagnotic procedures.

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We tried to apply an universal computer, NEC-PC 9801 E to the management of gastrointestinal endoscopic findings. We elaborated an original program using BASIC language and the original system for computerized management of gastrointestinal endoscopic findings. Merits of this system are mainly low-cost, easy to operate and available for various kinds of computers. The style to input the data is the dialogical system with CRT and the command menu, that is the data, consists of ten items. The code to input endoscopic diagnoses consists of 5 alphabets modified IRD code. Using this system, we can file information of about 4, 800 cases on one 8'2 DD floppy disket and can pick out desirable cases from filed 3, 000 cases within about 3 minutes. Furthermore, we can simultaneously analyse cases on different items. It is concluded that this system is very useful in terms of easy and rapid statistical analysis on cases undergoing gastrointestinal fiberscopy.

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We used TV-endoscope manufactured by Toshiba-Machida. This electronic endoscope did not have fiber bundles for imaging but CCD (Charge Coupled Device) in its tip. We could take an endoscopic picture made of about hundred thousand pixels. As it was of high resolving power, we could observe the fine structures of the mucosal surface which was not obtained by the fiberscope for routine examination. At present its operating activity and the recording system of this TV-endoscope remain to be improved but it has great possibilities of clinical applications such as computor analysis of the endoscopic image and developing the new recording system by using the video disc.

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