In order to improve pancreatic drainage, endoscopic pancreatic drainage (EPD) has been performed in 15 cases as a newly treatment method of chronic pancreatitis. EPD consists of pancreatic sphincterotomy, basket retrieval of calculi, and pancreatic endoprosthesis. Pancreatic sphincterotomy has been performed successfully in 12 of 15 cases, and followed basket retrieval stone in 2 cases, placement of pancreatic endoprosthesis in 3 cases. Through these newly procedures, clinical symptoms have been disappeared in 10 cases (83.3%) with improvement of pancreatic function. There have been no serious complications in our serieis, and moreover, we have recognized pathologically the security of pancreatic sphincterotomy by using the autopsy materials. It is concluded that endoscopic pancreatic drainage will be highly appreciated as a nonoperative treatment method of chronic pancreatitis.

View full abstract

To evaluate the incidence of recurrence of duodenal ulcer (DU), dyeing endoscopy in combination with methylene blue (MB) and congo red (CR) were performed in 150 patients (pts) with DU scar. MB absorption divided duodenal mucosal regeneration pattern into 3 groups as follows ;Group A : poor absorbing, Group B : fair absorbing, Group C : good absorbing, CR discolored pattern was categolized into 4 types as follows ;Type I : discolored border at the gastric angle, Type II: discolored border at the gastric middle corpus, Type III: discolored border at the gastric upper corpus, Type IV : so called "open type".Results : Retrospective study : There were 47pts (31%) in group A, 8lpts (54%) in group B, and 22pts (15%) in group C. Conversely, 44pts (29%) were in type I, 57pts (38%) were in type II, 36pts (24%) were in type III, and 13pts (9%) were in type IV.Group A consisted of 55% of type I, 32% of type II, 13% of type III, 0% of type IV, while Group C consisted of 9% of type I, 32% of type II, 41% of type III, and 18% of type IV. Out of 80pts who had the recurrence of DU in the past, 32pts (40%) were in group A, 42pts (52.5%) were in group B, and 6pts (7.5%) were in group C. Prospective study : A total of 110pts were followed up prospectively for a mean of 12.4±5.9 months (1-20 months). There were 29pts (26%) in group A, 62pts (57%) in group B, 19pts (17%) in group C, while 34pts (31%) were in type I, 43pts (39%) were in type II, 23pts (21%) were in type III, and l0pts (9%) were in type IV. Out of 110pts, 22pts (20%) had the recurrence of DU. The recurrence rate was 44.8% in group A, 41.2% in type I, and 57.9% in both group A and type I. Conclusions : In our study population, pts who belonged both in group A and type I at the same time, had higher recurrence rate of DU. It is concluded that dyeing endoscopy with combination MB and CR appeared to be effective for detestation of the recurrence of DU.

View full abstract

EUS was performed in 17 patients with esophago-gastric varices for the evaluation of EIS. Esophago-gastric varices before EIS were clearly displayed by EUS as lumens with low echoes, and the localization could be distinguished whether in the mucosa, submucosa or outside of the wall. After EIS, esophago-gastric varices were ultrasonographically confirmed to be filled with hyperechoic thrombus in the thickened wall, demonstrating variceal obstruction. Thereafter, the echogenic thrombus changed to uniform hypoechoic thrombus, indicating organization. In some patients observed for 3 months or more after EIS, a luminal image with lower echoes was detected within the hypoechoic thrombus. With additional EIS, the image showed recanalization. Recanalization was confirmed in all patients observed for 6 months or more after EIS. Observation of changes in varices after EIS and early diagnosis of recanalization were possible by using EUS. Thus, EUS is highly useful in evaluating the clinical effects of EIS.

View full abstract

In order to elucidate the mucosal pattern and superficial structure of neoplastic lesions in the gallbladder, the mucosa of 102 excised gallbladders (cholecystlithiasis, 82 cases ; adenocarcinoma, 8 cases ; adenoma, 2 cases ; normal gallbladder, 11 cases.) were observed by dye staining stereomicroscopy. The mucosal pattern of the gallbladders were classfied into the following 4 type ; reticular type, 50% ; hyperthorophic type, 15% ; atrophic type, 20% ; mixed type, 15%. The cancerous mucosa showed an irregularly granular, nodular and villous structure. The adenomatous mucosa showed a nodular structure. The differential diagnosis between cancer and adenoma was difficult macroscopically. These findings obtained by dye staining microstereoscopy for the mucosa of the excised gallbladders are very useful for the macroscopic and endoscopic diagnosis of gallbladder lesions.

View full abstract

We have reported three cases with antimitochondrial antibody (AMA) postive non A, non B hepatitis, especially on findings of peritoneoscopy and endoscopic retrograde cholangiography (ERC) in comparison with primary biliary cirrhosis (PBC). Titers of AMA were over 1: 320 (AMA subtype : Anti-M₂ and Anti-M4 were positive) in 25 years old female with acute non A, non B hepatitis, 1: 80 (AMA subtype : Anti-M₂ was positive) in 49 years old male with non A, non B chronic hepatitis, and over 1: 320 (AMA subtype : Anti-M₂ and Anti-M₄ were positive) in 53 years old female with non A, non B chronic hepatitis. All three cases showed elevated alkaline phosphatase, γ-glutamyl transpeptidase, leucine amino peptidase activity and Ig.M value in the beginning of the diseases, but later, these values were normalized or ruduced. Peritoneoscopy in these three cases revealed that there was no finding of rough bigger block (RBB) on liver surface, which is usually found in early stage of PBC as we have reported. Liver biopsy specimens also showed no histologic findings suggesting PBC in these three cases but healing stage of acute hepatitis in one case, and chronic hepatitis in two cases. X-ray examination of intrahepatic bile ducts (more distal branches than those of the 5th) revealed no findings of periductal oozing or dotted line appearance. These ERC findings have been frequently demonstrated in early stage of PBC as we have reported. Although there were no findings suggesting PBC except positive AMA in these three cases with non A, non B hepatitis, careful further following up was thought to be necessary.

View full abstract

Endoscopic injection sclerotherapy (EIS) for esophageal varices is being thought to be useful technique not only in emergency cases of raptured varices but also in prophylactic cases from esophageal varices. Recently, complications of EIS is being revalued for techniques and its prognosis. Among thirty patients who treated by EIS had esophageal varices more prominent than F₂ with RC sign, were investigated those complications from EIS by means of panendoscopy, blood chemistry and chest X ray examination. Ten patients (2 women, 8 men) had an acute episode of hemorrhage and/or woozing from esophageal varices, were controlled by emergency EIS. Two lethal cases out of theirty EIS series were experienced, one was due to re-bleeding from the varices after EIS and another case was died from bronchopleural fistula formation 30 days after EIS. They were included in emergency group. Two cases of transient lung thrombosis (one in emergency, one in prophylactic group) were observed. Ulceration of injection site of the esophageal varix was found 22 cases (Ca. 70%) out of 30 patients (7 of 10 emergency, 15 of 20 prophylactic group). We modified the Takase's method of EIS to reduce the complication such as re-bleeding and lung thrombosis that is deviling injection of 3 to 5 ml of 5% ethnoleamine oleate directly into every varix for 3 to 5 cm interval through 15 cm long. Two out of 30 series of EIS, we performed partial splenic embolization (PSE) for pre-treated medication of EIS, because those two cases showed marked hypersplenism with thrombocytopenia. Combination of PSE and EIS will diminish the bleeding after EIS.

View full abstract

Depending on the depth of defect of gastric mucosa, we classified gastric erosions into 2 groups ; deep erosion belonging to ulceration-I (U1-I) and superficial erosion belonging to ulceration-O (U1-O). (Murakami's classification of gastric ulcer as in Figure 6). From the view point of endoscopy, we discuss on visual estimation and histological findings of the superficial erosion (U1-O) as follows : 1. Erosion at active stage : U1-O¹ (Figure 8) reveals necrotic change in the epithelial surface. U1-O² (Figure 9) shows that the necrotic tissue is replaced by regenerative changes, but epithelial surface does presistently secrete in some parts. By endoscopic finding, it is seen as withish coat or slight redness (Figure 10). 2. Erosion at healing stage : U1-O³ (Figure 11) reveals as nearly complete regenerative changes. It is compatible with mucosal surface such as broad-based polyps, or a Belle of ètat mammelonnè. U1-O⁴ (Figure 12) reveals a slight depression covered with complete surface epithelium. Endoscopically it represents chronic gastritis. 3. Cancerous erosion : cancerous erosions of minute cancers such as type IIc and type IIa + IIc (IIc + IIa) are endoscopically shown at active stage or healing stage. From the mentioned above, it is important to state that such findings as cancerous erosion, U1-0 and U1-I develop not only on the nearly normal gastric mucosa but also on the mucosal surface of chronic gastritis. It is appearent until now that the differentiation between the benign and minute malignant erosions are difficult without microscopic examination such as biopsy and cytotogy.

View full abstract

Endoscopic pictures of healed total colitis were studied. An atrophic type was predominant among the cases healed with medical treatment (71%). On the contrary, a polyposis type was 50% in operated cases. Cases with inflammatory diverticulosis proved to be not so infrequent in our series. In most cases, the rectum showed the atrophic type. Inflammatory polyposis and diverticulosis were observed in the colon irrespective of anatomic location. Endoscopic findings of the healed ulcerative colitis was almost the same in the first and the following attacks. Polyposis vanished after three or more years of remission. Cases with deep ulceration at the active stage resulted in polyposis and/or diverticulosis type. Inflammatory diverticula ranged from deep to shallow, wide to narrow. They were established soon after the remission in 4 cases. However, they appeared after one year in 2 cases. In one case diverticula became deeper and extensive with a lapse of time. They vanished after a long period of remission except deep ones. Two cases with stenosis and one case with mesh-like lesion were noticed as rare examples of healed lesions.

View full abstract

We examined the specimen taken out from the body and water-immersed employing newly developed electronic endoscopes, the electronic endoscope of Welch Allyn Co. LTD., and that of Toshiba and Machida. The picture was as clear as stereoscopy. The use of oblique light didn't show much difference. As an experiment, we observed water-immersed mucosal pattern of crossbreded adult dogs' stomach and colon with the preparation of formalin fixed, and Alcian Blue, Hematoxyline stained. The picture was excellent. Clinical application were then tried. After making endoscopic preparation of pronase 20, 000, NaHCO₃ 2g, and gascone 30m1, we performed endoscopy as usual and made additional observation in water immersion. We obtained picture as that of stereoscopy. We would name the method for water loading electronic endoscopy and pursue it for the diagnosis of chronic gastritis or detection of very minute lesion.

View full abstract

Our previous report demonstrated that the duodenal wall could be separated into 5 layers or 9 layers by the endoscopic ultrasonography (EUS) and clarified the histological structure of these layers by compairing endoscopic ultrasonograms of resected specimens of the duodenum with their corresponding histology. Furthermore, we performed EUS in clinical cases. The results were as follows; 1) In 5 layers of the duodenal wall, the 1st and the 2nd layers corresponded to the rest of mucosa (except an area of glands of Brunner in the mucosa), the 3rd layer was consisted of the submucosa and a part of mucosa corresponding to the glands of Brunner, the 4th layer corresponded to the muscularis propria, and the 5th layer was consisted of the serosa and a border echo. 2) Glands of Brunner were demonstrated as hyperechogenic region. 3) When a thin layer was visualized at the same time in both the 2nd and the 4th layers in clinical cases, the duodenal wall was separated into 9 layers in total. 4) A thin layer in the 2nd layer was thought to be the glands of Brunner in the mucosa. A thin layer in the 4th layer of the duodenal wall seemed to be consisted of a border echo and a connective tissue between the inner circular muscle and the outer longitudinal muscle. 5) EUS was thought to be very useful for the diagnosis of the depth of the duodenal ulcer and the choice of its theraputic methods.

View full abstract

In order to protect bowing of redundant sigmoid colon, a splinting device has been commonly applied for total colonoscopy. However, an ordinary splinting device often causes a handling difficulty with the scope, because of the length of 40 cm near to control unit. In case of using an intermediate-length scope (i, e. CF10I in 1, 330 mm Olympus), we need a shorter one. A short splinting device (Mini-Sliding tube) is 21 cm or 26 cm in effective length, 15 mm in the inner diameter and 18.5 mm in the outer diameter, contrast to 40 cm of an ordinary one. Application of the short splinting device was carried out 1, 818 times during the recent 18 months with a success rate of 99.6% (1810 out of 1818). Telescoping of redundant sigmoid colon by means of the short splinting device offers possible advantages to perform the colonoscopic procedure. No complications were encountered during this procedure.

View full abstract

A case of congenital esophageal web is reported. A 71 year-old-woman gave a history of having difficulty in swalloing solid foods unless they were finely shredded as long as she could remember. She was diagnosed esophageal web by the endoscopic examination and X-ray studies. The web was thought to be congenital. Dilatation therapy using a balloon catheter with endoscopic small and thin incisions were performed. After these treatment for several times, she became able to swallow ordinary solid foods and it was possible to insert the fiberscope of 12 mm in diameter through the lumen.

View full abstract

This is a case report of a 72-year-old female with gastric ulcer associated with candida infection resulting in pyloric stenosis. A distal partial gastrectomy was performed for the pyloric stenosis. We thought that this case was primary gastric candidiasis by reason of the following three points. 1) Candida was recognized in the biopsy specimens of the first occasion. 2) Candida invaded to the bottum of the ulcer. 3) This ulcer grew worse by asministrating only antipeptic drug.The healing tendency was recognized by adding antifungal drug. The charactaristic endoscopic features of our case were the folowing 1) thick, dirty and yellowish white coating. 2) A circular giant ulcer involving whole part of the antrum and lower body of the stomach. 3) low but clear boundary wall. 4) existence of a deeper excavation in the bottum of the ulcer.

View full abstract

Schonlein-Henoch purpura occurs most commonly in children and rarely in adults. The entity of the abdominal lesions remains uncertain. This report is the presentation of a case of Schonlein-Henoch purpura with a statistic analysis of 28 adult cases examined by upper gastrointestinal endoscopy in Japan and some considerations about the etiology of the gastrointestinal involvement in this disease. A 52-year-old man noted the onset of purpura with systemic arthralgia and macroscopic hematuria. After 2 weeks, he suffered from severe hematemesis, melena, vomiting and abdominal pain. Endoscopic examination revealed spotty bleeding and erosions in the stomach, and duodenal ulcer. After taking H2 -receptor antagonist and adrenocortical steroid, his subjective symptoms and endoscopic findings prominently improved. The deposition of IgA positive substance at the wall of small vessels was seen by using enzyme-labelled antibody technique. The degranulation of masf cells was observed by electron microscopy. This degranulation was considered to be caused by the antigen-IgA immune complexes. These mechanisms were considered to be increasing the vascular permeability and to be involving the gastrointestinal lesions in this disease. It was suggested that the action of H2-receptor antagonist and adrenocortical steroid, inhibitting the increase in vascular permeability, was effective to these mechanisms.

View full abstract

A case of autopsy was described in which an attempt at percutaneous transhepatic cholangio-plasty (PTCP) with diathermic knife through the percutaneous transhepatic cholangio-scope was successful, with explanation of the instruments and techniques. The patient was an 84-years-old woman admitted for examination and treatment of jaundice, on whom percutaneous transhepatic cholangiodrainage (PTCD) was performed. Though periampullary cancer was diagnosed by imaging diagnostic method, percutaneous transhe-patic cholangio-scopy and biopsy, resection was considered impossible as the patient was a poor surgical risk. Local injection of mitomycin C through the percutaneous transhepatic cholangio-scope to the distal end of the common bile duct, which was almost totally obstructed, produced no effect, so that PTCP was performed. After PTCP, Al-P and serum amylase rose transitory, but no clinical symptom indicating complication such as cholangitis or pancreatitis occurred, and the elevation of serum enzyme levels were corrected in a short time. The patient died from cachexia at 8 months after PTCP. Between PTCP and death, the increase of bilirubin level was not detected, and the excretion of bile into the duodenum seemed good throughout this period, moreover, autopsy revealed that the patency of the internal fistula was maintained well. PTCP is advisable as a useful treatment for inoperable cases of obstructive jaundice.

View full abstract

A 48-year-old woman was admitted to our hospital complaining of tarry stool and anemia. Hypotonic duodenography showed the 2nd portion slight dilated, the 3rd portion severe dilated and a ping-pong sized tumor with bridging fold in the 3rd portion. Endoscopy of the duodenum showed the surface of the tumor with map like erosion and deep creft of the tumor. From the creft bile juice recognized flowing out. Preoperative diagnosis was submucosal tumor of the papilla of Vater. Tumor resection, sphincteroplasty and cholecystectomy was perfomed. Histpathological diugnosis was gangliocytic paraganglioma.

View full abstract

Four cases of choledochocele were reported and previous 16 cases reported in Japan were reviewed. One of our 4 cases was classified as a type A of the Sholz's classification. But other 3 cases could not be classified as his type A or B. Two cases like an Isawa's case were differen tiated from it in point of absence of fistula from the cele to the duodenum. One case was the new type of choledochocele, in that the orifice of pancreatic duct was independent of that of the common bile duct. Our new classification of choledochocele into five types (A-E) modifying Sholz's classification was presented.

View full abstract

Two cases of early cancer of the papilla of Vater were reported. Case 1: 72-year-old man was admitted to our hospital with a complaint of epigastralgia. Slight elevation of the serum LAP, AL-P and γ-GPT was detected. Hypotonic duodenography and duodenofiberscopy showed a polypoid lesion of the papilla of Vater, and the biopsy specimens revealed adenoma, but the presence of focal malignancy could not be ruled out, Amputation of the papilla of Vater was performed. The histology of resected specimen revealed adenoma with focal carcinoma. The postoperative course of this patient has been uneventful. Case 2:53-year-old man was admitted to our hospital with complaints of upper abdominal pain and back pain. Routine examinations revealed the elevation of serum amylase and mild liver function impairment. From this results, acute pancreatitis was suspected. The conservative therapy for pancreatitis was effective. Hypotonic duodenography and duodenofiberscopy showed a polypoid lesion of the papilla of Vater, and the biopsy specimens revealed adenocarcinoma. Pancreoduodenectomy was performed, and resected specimen revealed adenoma with focal carcinoma. The post operative course has been uneventful. These two cases suggested the possibility of malignant transformation of adenoma of the papilla of Vater.

View full abstract

We experienced a case of suspected Dieulafoy's ulcer (Du) after clipping operation for subarachnoid hemorrhage. We found a lesion of suspected Du in the duodenum and local injection of pure ethanol was performed under endoscopy. A 70-year-old female was admitted to our hospital because of convulsions, disturbed consciousness level and right hemiparesis. She underwent a clipping operation of the aneurysm on Mar. 26 '85 and tarry stools were followed 9 days later (Apr. 4). The endoscopy on the next day revealed a small blood clot (about 0.3 cm) and a navel-like protruded area (about 0.1 cm) on the mucosa of the superior duodenal angle (SDA) without any definite ulcers. We judged the blood clotted area to be a bleeding focus and 1.0 ml of pure ethanol was topically applied to that spot with a successful hemostasis. She, however died, on Apr. 10 due to post-operative cerebral edema. Histology of the SDA area disclosed Ul 2 ulcers and big persistent arteries in the submucosa. Du is known as a relatively rare disease usually seen in the stomach. However, this case is an extremely rare one found in the duodenum.

View full abstract

A 67-year-old woman was admitted to our hospital because of melena. The diagnosis of von Recklinghausen's disease had been made at the age of 22. Three similar episodes of melena occurred in these three years, but the bleeding site unknown. Three months before admission, she had melena, but upper and lower gastrointestinal series were normal. Radiographic and endoscopic examinations of the small intestine showed a small mass in the jejunum (Figure 1, 2). Abdominal angiography was performed and a tumor stain was noted (Figure 3). Partial resection of the jejunum was performed and microscopical examination of the tumor revealed a leiomyoma (Figure 4, 5-a, 5-b). Gastrointestinal tumors should be considered in von Recklinghausen's disease with gastrointestinal disorders. We reviewed 12 cases of von Recklinghausen's disease with intestinal leiomyoma from the literature (Table 2).

View full abstract

A case of submucosal lipoma of the colon was reported which changed in shape during the course of followed up examinations and was removed by endoscopic polypectomy. A 70-year-old woman was admitted to our hospital with a two-month history of left lateral abdominal pain. Barium enema examination on July, 4th, 1981 revealed a smooth semipedunculated polypoid lesion in the transverse colon (Figure 1). Colonoscopic examination one month later showed that the polyp had become sessile (Figure 2). The polyp changed in shape in 1984 again (Figure 3). Endoscopic polypectomy was performed on June, 26th, 1984. The removed tumor measuring 1.0 × 0.7 × 0.5 cm was smooth and soft. The pathological diagnosis was a submucosal lipoma (Figure 4). Fourteen cases of lipoma of the colon removed by endoscopic polypectomy has been reported in Japan. The endoscopic polypectomy would be a useful therapeutic and diagnostic procedure if the indication is determined carefully.

View full abstract

A 35year-old man was admitted to our hospital because of acute abdominal pain and bloody stool. Laboratory data on admission included WBC 13, 200, ESR 69mm/hr and CRP 2 (+). Urgent colonofiberscopy showed edematous mucosa and diffuse bloody mucosa at the descending colon. Biopsy specimen taken from the same place revealed "ghostlike appearance". Barium enema study on the same day showed "thumb printing" sign in the descending colon. Abdominal pain and bloody stool improved within four days. Laboratory data became normal range in a week. The second barium enema study performed at 11th day after onset showed a ulcer scars at the upper part and "sacculation" at the middle part of the descending colon. The second colonoscopic examination at 15th day after onset showed three longitudinal ulcers and edematous mucosa. The third colonoscopic examination at 60th day showed two longitudinal ulcer scars with converging folds. The last barium enema study at 68th day showed a scar of longitudinal ulcer with converging folds. On the basis of clinical and morpholgical views, this case was considered as the stricture type of ischemic colitis. It's chemical course was able to be observed from the very beginning to scarring stage.

View full abstract

In this paper, experience of postoperative choledochoscopy using CHF type 10 and P-10 was analized and its usefulness was discussed. During the period of 2years since June, 1983 to July, 1985, CHF type 10 and P-10 had been used for 209 times of choledochoscopy in 66 cases with intrahepatic stones or retained biliary tract stones. The improvements of CHF type 10 and P-10 on their predecessors such as CHF type B₂R and 4 B are reduction of outer diameter due to development of thinner glassf iber, biger angulation, increase in visual field. Moreover the time required for sterilization was remarkablly shortened because these two scopes are totally immersible into the solution of disinfectant. These improvements also provided a sharper definition of objects and reduced the limitation of field of vision. Moreover the improvements made it easier to manipulate the scope. No mechanical troubles had been encountered in this series. Therefore the authors believe that these two choledochofiberscopes can be used clinically and the therapy of biliary tract stones will be significantly improved if these scopes were routinely used.

View full abstract