To examine the clinical applicability and complications of ERBD in malignant biliary obstructive diseases, 198 patients were entered into this study. Eighteen patients (9.1%) were not indicated for ERBD due to extensive cancerous invasion to the duodenum or Vater's papilla. Among the remaining 180 patients, ERBD was successfully done in 155 patients (86.1%) and was effective in 142 patients (91.6%) from May, 1983 to November, 1985. The most frequent cause of unsuccessful ERBD was inaccessibility of Vater's papilla because of unsuccessful EPT. Precut patillotomy was attempted on 24 of the 180 patients (13.3%) and was effective in 14 patients. Early complications within 7 days after ERBD occurred in 23 patients (12.8%). There were no deaths associated with early complications. In 84 patients on ERBD for more than 60 days, late complications occurred on 75 occasions in 46 patients (54.8%). Most frequent late complications were clogging (44 occasions in 23 patients : 27.4%) and cholangitis (24 occasions in 21 patients : 25%). Thirteen patients died of such complications, 5 of them dying suddenly at home approximately 3 months after ERBD probably due to biliary septic shock. It is necessary to clean the endoprosthesis immediately by ERC when cholangitis develops, as cholangitis sometimes leads to a cause of death. Functional lifetime of a 10Fr polyethylene endoprosthesis was 154±69 days (range : 77 to 394 days), which was not necessarily shorter than that of a 12Fr tube. The important thing, therefore, was that the endoprosthesis should be cleaned endoscopically every 2 to 3 months for preventing clogging of the endoprosthesis and for prolonging its functional lifetime. ERBD is a safe and effective noninvasive biliary drainage method and is indicated for all patients with malignant obstructive jaundice in whom ERCP and EPT can be performed.

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Irregular surface of the liver is considered mainly caused by liver fibrosis. A total of 88 cases of liver specimen taken by laparoscopy from 1981 to 1985 were stained with aniline blue method. They were processed by personal computer. Then area of collagen fiber was quantified as area percent. They were compared with macroscopical liver surface findings. The percentage of collagen fiber area were 7.02±3.45% in chronic hepatitis and 13.78±5.16% in hepatic cirrhosis. The percentage of cellagen fiber area classified by laparoscopical liver surface findings were as follows. Type I smooth surface 2.99±0.01% Type IIa mild irregular surface 6.12±2.42% Type IIb moderate irregular surface 9.95±4.08% Type IIc severe irregular surface 10.41±5.97% Type IIIa moundlike nodular surface 14.46±6.01% Type IIIb dome-shaped nodular surface 13.61±3.12% The percentage of collagen fiber area had a tendency to increase with liver surface irregulality so that it was considered to be useful to indicate a degree of liver fibrosis objectively.

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We have performed endoscopic pancreatic biopsy (EPB) since 1983, and its evaluation from the experimental and clinical aspects has been reported previously. In this paper, we discuss the usefulness of EPB in clinical cases of pancreatic cancer. The subjects were 13 patients with pancreatic cancer encountered during the past two years. As reported previously, biopsy forceps were inserted from the orifice of the papilla via a duodenoscope, avoiding papillotomy, and EPB was performed. Among 13 patients with pancreatic cancer who underwent EPB, six of the ten with carcinoma of the head of the pancreas and two tail of the pancreas were positive for cancer tissues, showing a positive rate of 61.5%. The present study indicated that EPB can be relatively easily combined with endoscopic retrograde pancreatography (ERP) without causing any complications and that improvement in the positive rate is expected in the future. Therefore, we believe that EPB should be performed actively in patients in whom a pancreatic cancer is suspected.

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Using FACS III (Becton Dickison Co.), the amount of DNA was measured from strip biopsy and operative specimen from 20 cases of gastric cancer, 5 cases of group III lesions, 1 case of Cronkhite Canada syndrome, l case of pernicious anemia, and 6 cases of atrophic gastritis. We found the emergence of aneuploidy on 11 cases out of 20 cases of gastric cancer (55%). Classifying early cancer and advanced cancer, we recognized 67% of aneuploidy on early cancer and 38% of that on advanced cancer. Distinguishing from proliferation type, we found aneuploidy on 77% of well proliferated, 55% of moderate cases and 0% of poorly proliferated cases. Also, we detected one aneuploidy out of 5 cases diagnosed as group III histologically. It is conculded that we have reached the opinion that the method of Flow cytometry effectively provides objectively on more or less subjective histological diagnosis of group III etc.

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Seventy three patients performed endoscopic esophageal biopsy were included in this retrospective study in relation to the diagnosis and symptoms suggesting an esophageal disorder. They had no previous surgery of the upper GI tract and they were not the cases of emergency or early endoscopy at the time of biopsy. Fourteen esophageal carcinomas, including six early or superficial carcinomas, were encountered in this study. Significant symptom was apparent in patients with advanced carcinoma, while it was not present in patients with early or superficial carcinoma, except a case with ulcerated one. Fifty nine patients with benign esophageal disorder, such as reflux esophagitis, polyp, erosion etc., were often asymptomatic, except cases with esophageal ulcer not associated with reflux esophagitis. Therefore, panendoscopy is thought to be an excellent method as an initial diagnostic approach to the upper GI tract, especially in detecting unexpected esophageal disorders.

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Balloon catheter dilatation was evaluated for noninvasive treatment of strictures in the upper digestive tract. Balloon catheters of various size made by Microvasive Inc. in U. S. A. were used in this study. The procedure was done (under fluoroscopy) and a balloon catheter was inserted over a guide-wire which was previously passed through a stenosis by endoscopy. The technique was apllied in 10 patients with primary stenosis (2 of esophageal ulcer scarring, 3 of achlasia, 2 of esophageal cancer and 3 of gastric cardia cancer) and in 11 patients with postoperative stenosis (7 of esophageal cancer and 4 of gastric cancer). In all 21 patiests, relief of stenosis was successfully accomplished without any significant complications. Intubation of a endoprosthesis tube was done through the stricture after dilatation in 5 patients with primary stenosis due to malignancy (3 of esophageal cancer and 2 of gastric cancer). It is concluded that balloon catheter dilatation is an easy, safe, effective and comfortable procedure to patients with stricture of the upper digestive tract.

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Strip biopsy is a newly deveroped technique of endoscopic gastric mucosal resection. This technique is a very safe method, but it causes an artificial ulcer (U1-2) at the site of resection. In this study, we examined 11 lesions of post strip biopsy ulceration, and the average age of patients was 73.3 (×5.6 SD). Histamine H2 blocker, such as ranitidine (300mg/day) or cimetidine (800mg/day), was used in every case. It was observed that, many of artificial ulcers healed by the end of the 4th week, and the grade of antral gastritis had no relation to healing period. But those ulcers which healed after the 4th week had a larger diamater than those healed in the 4th week. 27% of the cases had a protruded scar caused by foveolar epithelial hyperplasia. Strip biopsy induced human gastric ulcer was considered to be a model of acute gastric ulcer, and it seems to be significant as a normal control in the ulcer healing process.

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Transcatheter Arterial Embolization (TAE) and Intra-Arterial one shot Injection Therapy (TAT) were performed to treat patients with primary hepatoma. TAE was performed in 15 patients, TAT in 11. Gastroduodenal endoscopic examination was carried out in every case before and after TAE or TAT. Preexisting gastroduodenal ulcers did not worsen after therapy. The incidence of gastroduodenal lesions and symptoms was signifi-cantly higher after TAE than after TAT (P<0.05 ; P <0.01) (Figures 1, 4). Chemoembolization caused much more gastroduodenal lesions than simple TAE without anti-cancer agents (P<0.05) (Figure 3). When more than 15 days passed after TAE, the incidence of gastroduodenal ulcers significantly increased (P<0.05). Cimetidine showed no prophylactic effect on gastroduodenal lesions. Results of serum amylase and abdominal echogram revealed that epigastralgia after TAE or TAT might not be correlated to pancreatitis or cholecystitis. These findings suggest that it is necessary to pay more attention to gastroduodenal lesions following TAE than following TAT, especially following chemoembolization.

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Endoscopic and clinical features of acute duodenal mucosal lesion (ADML) have not been clearly described. In this study, endoscopic findings of ADML were defined as follows : (1) irregular shaped erosions partially covered with white mucous material, (2) pin point necrotic tissue observed in the erosions, (3) the erosions surrounded with edematous mucosa, (4) mainly the first portion and sometimes the second portion of the duodenum affected by ADML, and (5) complete disappearance of the mucosal lesion within one week after starting medical treatment. Thirty-two patients who were revealed to have the above mentioned findings in the duodenum were chosen from 6074 patients examined endoscopically. The ages of the patients ranged from 10 to 70 years, and male was 7 times as many as female. The symptoms frequently observed were epigastralgia, nausea, and vomiting. Acid out put was increased in all of 15 patients for whom gastric secretion was examined by tetragastrin stimulation. ADML was cured without leaving scar by rest and drug treatment.

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A 61-years old woman visited our hospital, suffering from 3-day lasting epigastralgia and anterior chest pain on swallowing after taking a turbot. A fish bone was found to be lodged at its both end to antero-posterior wall of esophagus at the level of 30 cm from the upper central incisar by endoscopical examination (Figure 1-A), The 4.5 cm-long fish bone which penetrated through anterior esophageal wall was successfully removed with forceps under endoscopy. Esophagogram revealed the formation of peri-esophageal abscess (Figure 5) due to esophageal perforation caused by the fish bone. Since her general condition was relatively good without any severe complications, she was conservatively treated with antibiotics medication and total parental nutrition under withdrawal of all oral intake. The lesion was confirmed to heal on the 20th hospital day. Esophageal perforation caused by a foreign body frequently involves severe compilica-tions. In the present case, early remoral of a foreign body may result in good clinical course.

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We report a rare case of Behcet's disease complicated with esophageal ulcers. This 59 year-old male patient had post-sternal pain, back pain, stomatitis, fever and dysphagia in Jan'85. Despite the anti-ulcer therapy, he grew worse in the esophageal ulcer and the subjective symptoms. So, he was admitted to our hospital for close examination in May '85. The laboratory studies on admission showed that he had an active inflammation. The endoscopic examination demonstrated several round-shaped clear-cut ulcers in the lower esophagus. The histology of the biopsied tissue revealed granuloma formation and round cell infiltration. We made a diagnosis of Behcet's disease because he had stomatitis, chronic uveitis and a G. I. tract disorder (esophageal ulcer). He started to have a fever, which was refractory to any antibiotics in May '85, which however subsided soon after the application of steroid therapy. The esophageal ulcer also became normal endoscopically and he was discharged in good condition in Aug. '85. It is very rare for the patient of this disease to have lesions in the upper G. I. tract and only 26 such cases were reported till now in the world. In 11 cases, the lesion is localized to the esophagus. So, we report this extremely rare case with some bibliographic discussions.

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A case of esophageal ulcers associated with pivemcillinam hydrochloride (PMPC) therapy was reported. A 28 years old man came to our hospital because of the onset of retrosternal pain. He had taken one PMPC tablet without water the previous night just before going to bed. The roentogenogram of the esophagus revealed faint barium flecks of the mid-and lower-esophagus. Esophageal endoscopy revealed five sharp round ulcers in the mid-esophagus, 23 cm to 28 cm from the incissors. Esophageal endoscopy showed that the ulcers completely healed after 32 days. This case was the second case induced by PMPC reported in Japan. The Etiology of this case was discussed.

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A 34-year-old male admitted to the Toho University Hospital for the evaluation of liver dysfunction. He had no history of alcohol ingestion. His body weight was 55 kg and his height was 157.5 cm. On admission, the liver was palpable 3 cm below the right costal margin and biochemical data showed mild hepatocellular injury (GOT 42 units, GPT 85 units and γ-GTP 108 units). Latent diabetes mellitus was disclosed by glucose tolerance test. Since hepatic ultrasonography and CT strongly suggested the presence of fatty metamorphosis, especially located in the left liver lobe and the anterior area of the right liver lobe, peritoneoscopy was performed. The liver was swollen, and the surface was smooth and yellowish. Magnifying peritoneoscopy revealed so-called "leopard skin-like spotting". After indocyanine green (ICG) 200 mg was administered intravenously, the outline of hepatic lobules was accentuated and the areas of central vein were stained. Liver biopsy specimen revealed numerous deposits of large fat droplets, mainly distributed in the centrilobular and midzonal areas. The findings obtained by the magnifying peritoneoscopy combined with ICG staining method were well corresponded with such histological findings.

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We experienced a case of adenomyomatosis of the gall-bladder associated with abnormal anastomosis of the pancreatic duct and bile duct. A 35-year-old woman. Visited our clinic because she occasionally experienced a dull pain from the right hypochondrial region to the back since March, 1981. ERCP revealed a spot like shadow encompassing the external margin of the gallbladder. These findings corresponded to those of adenomyomatosis. Moreover, abnormal anastomosis of the pancreatic duct and bile duct forming a common channel of 25 mm in length was noted. An echogram and CT scan also indicated hypertrophy of the entire circumference of the wall of the gallbladder cavity and small stones were also shown. Therefore, cholecys-tectomy was performed. The amylase concentration of bile juice in the gallbladder during operation was 18, 060 s. u./dl. The histological findings revealed glandular proliferation and a proliferation bundle composed of smooth muscle cells. From these findings, it was suggested that an elevated bile duct pressure due to the abnormal confluence of the pancreatic duct and bile duct and repeated occurrence of inflammatory chronic stimuli might be the cause of adenomyomatosis of the gallbladder.

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A thirty two y/o female was admitted to our hospital because of watery diarrhea, weight loss and rheumatoid arthritis. X-ray and endoscopic examinations of the gastro-intestinal (GL) tract revealed coarsening mucosa and edematous fold. Deposits of amyloid were seen by histolosical study of the biopsy specimens of the GI tract. Subsequentry diagnosis of secondary amyloidosis was made. With treatment of IVH and DMSO in hospital course, coarsening mucosa and edematous fold of the GL tract gradually improved and deposits of amyloid were decreased and limited aroud the vessels. However she ultimately died renal failure.

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A 72-year-old male was admitted to our hospital, complaining of right subcostal pain. He was diagnosed as cholecystitis with cholelithiasis by laboratory findings and ultrasonography, and medically treated. However, right subcostal discomfort persisted after treatment. Upper gastrointestinal radiography performed and demonstrated a protruded lesion at the descending portion of the duodenum. Duodenoscopy revealed a smooth, yellowish and ovoid semipedunculated polyp with brideing-fold. Abdominal computed tomography (CT) showed that the tumor had-23 of CT number and it seemed to contain fatty tissue. For the purpose of histopathological diagnosis and treatment, the tumor was removed by endoscopic polypectomy. No complication was encountered and the complaint disappeared. The resected tumor was 15×15×18 mm in size and histopathologically, it was benign submucosal lipoma. Lipoma of the duodenum has been reported 41 cases throughout Japan, and endoscopic polypectomy was performed 13 cases. About half of the reported lipomas are peduncular or semipeduncular so that the cases of endoscopic polypectomy may be increasing for the future.

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A 29-year-old man was admitted with weight loss and lower abdominal pain. Eight years, befor he was admitted to our hospital due to hematoemesis and urgent endoscopy revealed duodenal ulcer at that time. Since then, he has visited our clinic freqnently. On this admission, laboratory data showed hypochromic anemia, accelated ESR and positive CRP. Since 19 76, upper gastrointestinal endoscopy has been often performed, and erosion or redness were obserbed in the gastric antrum and multiple small ulcers in the duodenal bulb. On this admission, noncaseating epithelioid cell granuloma was confirmed in the biopsy specimen taken from the gastric antrum. Barium enema study and colonofiberscopy showed the typical findings characteristic of Crohn's disease such as longitudinal ulcer and cobble stone appearance and noncaseating epithelioid cell granuloma was confirmed in the biopsy specimen taken from a lesion of the large intestine. This is a very interesting case of Crohn's disease in which upper gastrointestinal lesions have been observed for 8 years.

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A 80-year-old male was admitted to our hospital because of abdominal pain and tarry stool. Chest X-ray film revealed a tumor shadow in the left lower lung field. And cytologic examination of sputum suggested squamous cell carcinoma of the lung. Moreover, roentogenography and endoscopy of the small intestine revealed protuberant lesion in 30 cm anal side of the ligament of Treitz. Biopsy specimen from this lesion did not show malignant findings. However, laparoscopic examination revealed a hens' egg-sized, white medullary and cauliflower-like tumor on the serosal surface of the small intestine. And biopsy specimen from this tumor showed squamous cell carcinoma. Based on this finding, a diagnosis of metastatic small intestinal carcinoma, secondary to the lung carcinoma was made. Operative findings revealed six metastatic intestinal carcinoma, consisting of 2 lesions in the jejunum, 2 lesions in the ileum and 2 lesions in the transverse colon. The incidence of metastatic small intestinal carcinoma, secondary to the lung carcinoma is few and making diagnosis for small intestinal lesion is difficult. Therefore, it is very rare to make a diagnosis before operation or autopsy like this case. In this case, laparoscopic examination was thought very useful for making a diagnosis.

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This case report describes a patient with Klippel-Trenaunay-Weber syndrome as-sociated with severe varicose-like lisions of the rectum. A 53-year-old female was admitted to our hospital because of severe anemia. At the age of seven, vascular nevus, varicosities and hypertrophy of right leg had appeared. At the age of thirty-one, she noticed melena and had received the resection of hemorrhoids. In spite of the operation, the melena had not improved. Because of the long lasting melena, anemia had been gradually progressed. At the time of admission, hemoglobin concentration was only 2.2 g/dl. The abdominal angiography showed venous dilatation, pooling of contrast medium and many phleboliths. The colonoscopic examination revealed multiple internal hemorrhoids on the anal ring and remarkably dilated vessels on mucosa of the rectum and the middle of the sigmoid colon. These findings are considered as the complications of alimentary tract of this syndrome. This case is presented here because the colonoscopic examination is less frequently carried out in this syndrome.

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More than 190 cases of juvenile polyp were reported in Japan, in which only two cases were found in the ascending colon. Therefore, this is thought to be the 3rd report of ascending colon polyp in Japanese literature. A 10-year-old girl was refered to us for further evaluation of bloody stool. Barium enema showed a pedunculated polyp (IV-type of Yamada and Fukutomi's classification) with a slightly uneven surface which revealed a two-headed polyp with partial hemorrhage by colonoscopic examination. The specimen obtained by colonoscopic polypectomy was elastic firm and had two heads, 2.2×1.4 cm and 1.6×1.0 cm in size, respectively. The cut-surface showed small multiple cystic lesions. Histological study revealed cystic formation with dilated glands and interstitial edema, which finding was compatible with juvenile polyp. This case was considered to be unique because of abundant eosinophilic infiltrations, which may be related to the etiology of this disease.

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42 cases of double pylorus, including our case, have been reported in Japan. Recently we experienced a case of congenital double pylorus. A 79-year-old male visited our clinic with a chief complaint of epigastric discomfort. Since X-ray examination of the upper gastrointestinal tract revealed a polypoid mass in the duodenal bulb, endoscopy was subsequently performed. Endoscopically, "double pylorus", the condition in which the pyloric ring has been divided into two portions by a band extending from the anterior wall to the posterior wall, found. Since this patient had no past history of peptic ulcer and historogical findings of biopsy specimens from the band showed no ulcerative changes and inflammatory fibrosis, it was considered to be a case of congenital double pylorus.

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We often encounter patients who, for variety of reasons, have lost the ability to swallow and require long term nutritional support but have an intact gut. To such patients, the conventional approach has been achieved by either naso-gastric, naso-enteric or surgically placed gastrostomy tubes. These methods have several disadvantages and all may result in undesirable side effects. Ponsky reported a new non-operative endoscopic technique for gastrostomy tube placement. We have adopted his method to 3 patients with cereberal damage. All cases were successfully and safety performed with this technique. From these results, it has shown that this method is effective and safe procedure.

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