By using transesophageal real-time two-dimensional Doppler echography the azygos vein, intercostal vein and the esophageal varices were investigated in 19 patients. Most of them had some varices in the esophagus. The azygos vein was visualized from the upper esophagus in all the patients. Color flow mapping was possible in 17 out of the 19 patients. In the remaining two patients, whose azygos vein had been ligated and divided at previous operation, the azygos vein was visualized however it could not be visualized in color. By using the fast Fourier transform, both the flow patterns and the flow velocity were analyzed in fifteen patients. The flow pattern was pulsatile in thirteen patients. Two periords of peak flow were detectable in each systolic and diastolic phase. A constant flow pattern was observed in two patients. The mean value of maximal velocity was 57±20cm/sec. Both the esophageal varices and the intercostal vein were visualized in color in 9 patients. This half-invasive method seems very useful for the evaluation of hemodynamics of the azygos-and variceal venous flow.

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The artificial duodenal ulcers which are produced endoscopically by strip biopsy are UL-II in depth, and their healing process may be thought of as a model of clinical acute duodenal ulcers. In experimental (canine) studies, 1 week after ulcer formation in non-Brunner's gland area, regeneration epithelium may be observed as comb like shape under dissecting microscope. And at the same time, the regeneration epithelium has no generative cell. After 3 weeks, the regenerative epithelium grows to tear drop shaped regeneration villi, and many generative cells can be detected in the cryptoid portion with the bromodeoxyuridine (BrdUrd) labeling method. But in Brunner's gland area, 1 week after ulcer formation, Brunner's gland situated under the ulcer floor, changed its acini flattend, got many generative cells and already produced regeneration epithelium. In conclusion, Brunner's gland play a very important role in duodenal ulcer healing.

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The acute gastric mucosal lesion (AGML) of the antrum, so called the antrum-type AGML is a clinical entity which initiates with severe epigastric pain and shows various mucosal changes such as multiple hemorrhagic erosions, marked edema and others. We could detect five layers of the gastric wall in 12 of 13 patients of AGML by the method of percutaneous ultrasonography (US) with stomach filled with water. The third layer of the stomach in these patients was diffusely and severely swollen, but the other layers remained within normal range. The mean thickness of gastric third layer in AGML was 6.1±1.0 mm, and this was significant (p<0.01) as compared with those in control groups. The mean thickness of gastric third layer observed within four days and over five days of the onset were 6.1±1.0 mm and 1.6±1.1 mm, respectively. This means that the thickening of the third layer rapidly improved in parallel with the clinical course of AGML and normalized within a week. We proved that the marked thickening of gastric third layer in the initial stage of AGML was the representation of severe edema in the tunica submucosa and that this finding on US was one of the characteristic features of AGML. Because the procedure was easy and non-invasive, we could apply this to early differential diagnosis and follow-up study for the patients of AGML.

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From October 1984 to March 1987, we carried out 48 total colonoscopies in 44 infants in whom 12 were under one year. As the results, 10 cases of intussuception, 10 cases of acute hemorrhagic colitis, 1 case of juvenile polyp, 1 case of colonic polyposis and 2 cases of Hirschsprung's disease were revealed. We performed colonoscopic examinations with mild anesthesia non-fluoroscopically. Urgent total colonoscopy was done in 19 patients less than 6 year under the diagnosis of acute abdomen because of bloody stool. The results revealed 10 cases of intussuception and 8 cases of acute hemorrhagic colitis. This indicates that application of total colonoscopy in infants is useful in diagnosing the deseases of the lower digestive tract in emergency cases. We treated intussuception endoscopically by sending air through endoscope and had successful reduction in 8 cases. We have performed pediatric total colonoscopy under mild anesthesia non-fluoroscopically and have had good results. We conveniently call our method 'non-invasive examination of large bowel'. We believe that this is the best method to diagnose infant colorectal diseases.

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Endoscopic microwave coagulation therapy (EMCT) was applied to 25 patients of postoperative anastomotic stenosis (14 cases of gastric cancer, 8 of esophageal cancer, 2 of esophageal varices and one of rectal cancer). Clinical symptoms and endoscopic findings were improved by EMCT in all cases without any significant complications. The sufficient effect was obtained in 19 cases (76.0%) after only one EMCT, but more than two sessions of EMCT were needed in 6 cases (24.0%). On the other hand, these anastomotic stenoses were classified into two groups. One was membraneous and another was non-membraneous. N on-membraneous types needed more times of EMCT (2.1 on the average) than membraneous types (1.1 on the average). Re-stenosis occured in only 3 cases among 8 of postoperative stenosis of esophagogastrostomy. It was considered that the re-stenoses were influenced by reflux esophagitis. It is concluded that endoscopic microwave coagulation therapy is a safe and sure method for the treatment of anastomotic stenosis after gastrointestinal operation.

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From 1975 to 1986, we have experienced 11 cases of duodenal adenoma among 79 cases of benign elevated lesion of duodenum (Table 1). We analized clinicopathologically these cases with adenoma and the following results were obtained. 1) Male-female ratio was 8: 3 and average age was 55.4 years. All eleven cases localized in 1st and IInd portion of proximal duodenum. Macroscopically, 8 cases showed non-sessile elevated lesions (Table 2). 2) These adenomas showed various histological atypia (Table 3, 4). One small tubulo-villous adenoma showed high grade atypia and immunohistochemical CEA. CA19-9 localization were positive in adenoma. These histological and immunohistochemical findings suggested that this small lesion was pre-malignant (Figure 4-b, c, d). 3) Endoscopically, cases of low grade atypia showed smooth, whitish and wellglistened surface (Figure 2-a, b). Cases of high grade atypia showed granular, red and ill-glistened surface (Figure 4-a, b). 4) Small duodenal adenoma (0.7 cm in size) of 24 years old male which was associated with Familial Adenomatosis Coli showed moderate atypia and slightly positive localization of CEA. CA19-9, and suggested malignant potentiality. 5) Histologically all of adenomas uncle 3 cm in diameter were tubular adenoma and the large adenomas over 3 cm were tubulo-villous adenomas. Duodenal adenoma may be initiate with tubular pattern in early stage and composite with villous pattern as it develope to large tumors. 6) We suspected as two types in duodenal adenomas that one was remained in adenoma but another type adenoma showed increasing atypia and finally transformed to adenocarcinoma as it developed.

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Polyethylene glycol electrolyte lavage solution (PEG-ELS) is a new nonabsorbable and nonsecretory gut lavage solution; its effectiveness in preparation for colonoscopy is already reported in the Western nations. However, the preparation methods varied among reports. We tried to settle the most effective way of prearation with PEG-ELS. Seventy six connective patients were randomly assigned to the following three groups. In Group 1(n = 25), PEG-ELS was administered on the day of colonoscopy without dietary restriction on the previous day. In Group 2 (n = 26), it was administered on the previous night of the examination without dietary restriction. In group 3, PEG-ELS was administered after dietary restriction with low residue diet on the previous day. The bowel cleansing effect and patient acceptance were compared among the three groups. As a control group, 25 cases with Brown's regimen were used. The bowel cleansing effect was the following order : Group 1 > Group 3 > Group 2 > Brown's regimen. In group 1, however, large amount of fluid was present in the colon, which necessitated frequent aspiration for colonoscopic insertion and observation ; in contrast, fluid retention was minimal in Group 2 and Group 3. Concerning patient acceptance, the order was the following : Group 1 > Group 2 = Brown's regimen > Group 3. In conclusion, PEG-ELS was the most effective and conf ortable when it is administered on the day of examination. However, there exists the possibility that minute lesions are overlooked by the fluid in the lumen. Exclusion of the fluid is the most important problem. When PEG-ELS is given on the previous night, low residue diet should be combined. Since fluid retention is minimal, this method can also be applied to preparation for barium enema. However, improvement on patient acceptance is desired.

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This report describes a case of small carcinoid tumor of the esophagus. A 59-year-female was admitted to our hospital on March 12 th, 1986 for evaluation of the esophageal polyp. Roentgenographic examination revealed a sessile polypoid lesion at the upper esophagus. Esophagoscopy revealed a smooth and slightly reddened tumor surface with positive Lugol stain. Endoscopic ultrasonography demonstrated a tumor existing in the mucosal layer of the esophagus. In the resected specimen, the polypoid tumor measured 1.0×0.9×0.5 cm in dimensions. Histologically, tumor cells showed ribbon or trabecular arrengement and Argyrophilia. Immunohistochemical study revealed that γ-enolase, calcitonin, and calcitonin gene related peptide were positive in tumor cells, indicating a calcitonin-producing carcinoid. Four carcinoids of the esophagus have been reported to date heretofore, but without immunohistochemical data for neuroendocrine nature.

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A case of congenital bronchoesophageal fistula without esophageal atresia, "H" type, in an adult is presented. The present case is a 58-year old woman with a history of chronic cough at meals. X-ray examination with barium swallowing revealed a fistula of the esophagus communicating with the right lower lobe bronchus. Esophagoscopy showed an orifice of the fistula, located 28 cm from the row of teeth, on the anterior wall of the esophagus, and there was an esophageal mucosal brigde near the orifice of the fistula. Most of such cases have been usually cured by the operation, The authors, however, tried closing the fistulous tract with injection of methyl cyanoacrylate (Alonalpfha A) under the esophagoscopy. One month late the trial, X-ray examination revealed the recanalization of the fistula. The second endoscopic closure was made with methyl cyanoacrylate and with intramucosal injection of OK-432 (Picibanil) on the oral side of the esophageal orifice to make an inflammatory mucosal protuberance. Eight months after treatment, the patient is free from symptoms. The literature of congenital esophago-pulmonary fistula without atresia in adults were reviewed and brief discussion on the diagnosis and the treatment was made.

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A rare case of esophageal leiomyoma with a large ulceration is reported. A 71-year -old woman was admitted to our hospital complaining of epigastric pain and slight dysphagia. A large tumor shadow was found in the right mediastinum on a plain x-ray film of the chest. A CT-scan revealed a tumor derived from the mid-esophagus, mainly growing toward the right posterior mediastinum. The CT-scan also detected an ulceration on the part of the tumor protruding in the esophageal lumen. On barium x-rays and endoscopy, the lesion was diagnosed as an extramucosal tumor with a large ulceration, involving about 10 cm in length of the middle part of the esophagus. Although biopsy failed in the histologic diagnosis, the lesion was diagnosed as a smooth-muscle tumor from the roentgenologic and endoscopic findings. The surgically resected specimen showed a large tumor which markedly developed outside the esophagus. The sizes of the tumor and ulceration were 7×4×5 and 3×1cm respectively. Histologically, the tumor was leiomyoma consisting of spindle-shaped cells with no nuclear mitosis. Esophageal leiomyoma associated with ulceration as presented herein is very rare. According to Bruneton et al. reviewing 700 cases of smooth-muscle tumors in the alimentary tract, the incidence of leiomyoma associated with ulceration in the esophagus is only 1.4%. In Japan, such a case has not been reported.

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A 75-year-old female admitted to our hospital because of right hypochondralgia and back pain. Ultrasonography, computed tomography, ERCP and angiography showed the findings of the gall bladder cancer invaded into the liver. According to the encasement of the portal vein and gastroduodenal artery, the operative treatment was thought to be impossible, so one shot therapy of Mitomycin C (MMC) into the gastroduodenal artery was done. After the therapy, she had melena. Endoscopic findings revealed the bleeding from gastric cancer, Borrmann III type on the posterior wall of the upper body. Bleeding was stopped conservatively. One shot therapy of MMC and Adriamycin into the freeding artery of the gall bladder cancer and gastric cancer was done twice, and two weeks after the last therapy she was died of blood loss from gastric cancer. Autopsy revealed the adenosquamous carcinoma of the gall bladder and adenocarcinoma of the stomach, namely synchronous double cancers. According to literature, there were 9 cases of the double cancers of the gall bladder and stomach in Japan. Clinical diagnosis of such cases may increase owing to the development of ultrasonography and endoscopy. Only one case of the same histological combination of this type of double cancers was reported in Japan previously. The origin and cause of adeno-sqamous carcinoma of the gall bladder is also discussed.

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We reported a 34-year-old patient with Wilson's disease. Although he presented neurological manifestations on admission, they disappeared after treatment with D-penicillamine. Before treatment, ultrasonographic finding showed multiple hyper-echoic and hypo-echoic space occupying lesions in the liver. Peritoneoscopic picture showed various sizes of yellowish or dark brown degeneration nodules in the liver. Biopsy specimen revealed remarkable fat and copper deposits in the liver. After treatment with D-penicillamine, ultrasonographic finding of the liver turned to be normal. Peritoneoscopic picture showed flattened nodules of the liver and yellowish or dark brown color was reduced. Fat or copper deposits of biopsy specimen were also markedly reduced.

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A case of gastric serosal cyst diagnosed preoperatively is reported. The patient was a 43-year-old man, who had suffered from mild abdominal pain after drinking for the past ten years. A cystic lesion between the stomach and the pancreas was formed by abdominal ultrasound examination. The cystic lesion was 4×2.2 cm in size with a oval shape. Endoscopic ultrasonography demonstrated each gastric layer adjacent to the cystic lesion was intact, and the cystic lesion was clearly marginated from the pancreas. ERCP and enhanced CT scan revealed no connection between the cystic lesion and the common bile duct, the pancreatic ducts, or blood vessels. From these observations, a peritoneal cyst between the stomach and the pancreas was suspected. An exploratory laparotomy demonstrated an unilocular gastric serosal cyst, 3×4×5 cm in size, with a serous content. Although peritoneal cysts are rarely found and seldom diagnosed prior to operation, the preoperative diagnosis was possible in the present case. The ultrasonographic examinations, especially the endoscopic ultrasonography appeared to be useful and most potent to establish the diagnosis.

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We report a case of porphyria cutanea tarda (PCT) without skin lesions. The patient, a 52-year-old male drinker, was admitted because of liver dysfunction and resting finger tremor. Under laparoscopic examination, on uneven surface of the liver the dark purple colorations from 0.2 to 1.0 cm in diameter were found. The liver biopsy specimen showed a strong red autofluorescence under ultraviolet light of Wood's lamp. Since the examinations of porphyrins showed the increased content of uroporphyrin in urine, the patient was diagnosed as PCT. Laparoscopic examination led to the diagnosis of this case of PCT without skin lesions. And we found that the dark purple colorations characteristic of PCT on the liver surface were showed even in the case without skin lesions.

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This case report describes a patient of Crohn's disease with duodenal involvement. A 25-year-old man was admitted to our hospital complaining of diarrhea and fever in May, 1983. He had been treated for small intestinal and colonic Crohn's disease since the first admission. At the first admission, endoscopic examination showed an ulcer scar in the duodenal bulb but granuloma was not found in the biopsied specimen obtained from the duodenal lesion. In January, 1984, endoscopic examination showed a duodenal ulcer and he was then admitted again for a pyloric stenosis in February, 1984. Endoscopic examination showed multiple elevated lesions in the duodenal bulb with annular stenosis. Surgical resection of the stenotic lesion of the duodenum was performed in May, 1984. The duodenal wall of the resected specimen was thick and histologically, granulomas were found. Therefore, this was diagnosed as duodenal involvement of Crohn's disease. In March, 1986, a stenotic change was observed in the colon but no duodenal stenosis recurred, regardless of occasional appearance of erosions in the remaining duodenum.

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A 24-year-old male with a chief complaint of left lower abdominal pain was referred and admitted to Koto General Hospital. Physical examination revealed tenderness and Blumberg's sign in the left lower abdomen. Laboratory findings showed leukocytosis (11, 600/mm³) and positive CRP indicating mild inflammation. Barium enema on the 3rd hospital day revealed diverticulum in the lower descending colon and an extrinsic compression with speculations of the bowel wall around the diverticulum. The contour of the diverticulum was irregular and the descending colon showed spasticity and distorted haustration. Colonoscopy identified the orifice of the diverticulum and the mucosa of the orifice was normal, but an extrinsic compression, redness, and edema were observed in the surrounding area of the diverticulum. Antibiotics (CEZ, CMZ, OFLX) were given and the symptoms and clinical findings improved rapidly. Colonoscopy on the 16th hospital day was unremarkable and barium enema on the 20th hospital day was normal except for the diverticulum, which contour was smooth. He was discharged on the 24th hospital day. Cases of left sided diverticulitis in the young in Japan were reviewed.

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A case of ischemic colitis associated with multiple sclerosis was reported. A 34-year-old female developed multiple sclerosis at the age of 16. Since then remissions and excerbations were repeated. In Jan. 1986, paraplegia, urinary retention and constipation developed and she was admitted to our department in Feb. 1986. Bilateral blindness, complete flaccid paralysis and loss of sensation due to transverse lesions of the thoracic spinal cord were observed although consciousness was clear. No bowel movement occurred for 2 days followed by anal bleeding. Colonofiberscopy performed on the same day revealed marked edema, indistensibility of the bowel, redness and bleeding in the sigmoid colon. Melanosis coli was also observed. Biopsy specimen demonstrated necrosis and "bursting" of the tubules (ghost like appearance) as well as the finding of nonspecific inflammation. The anal bleeding decreased gradually and ceased 4 days later. Barium enema and colonofiberscopy performed on 8 and 39 days after the anal bleeding were unremarkable, respectively. A diagnosis of ischemic colitis was made from clinical course, endoscopic and histologic findings. Mechanism of the onset of ischemic colitis in multiple sclerosis was discussed.

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Six patients with Crohn's disease initially diagnosed by colonic small and/or aphthoid ulcers were studied by X-ray and endoscopic examinations concerning the alteration of these lesions. Multiple small and/or aphthoid ulcers were disappeared with medical treatment in 4 out of 6 patients and those changed to localized cobble stone appearance in one patient and a characteristic cobble stone appearance was noted in the last case who did not have medical treatment. In those with colonic multiple small and/or aphthoid ulcers, extraintestinal signs such as aphthous stomatitis, arthralgia, erythema nodosum and fever were frequently encountered. It is consequently considered that the development of multiple colonic aphthoid ulcers is one of the signs of systemic manifestation of Crohn's disease.

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Since 1981, in Nagoya first hospital Japan red cross endoscopic removal of swallowed foreign bodies were successfully carried out to 16 young patients under the age of 14. All the foreign bodies were removed by using panendoscopes Upper GI endoscopy was performed under general anesthesia in patients under the age of 5. When the patients was older than 6 and comprehensive, patients were examined with topical pharyngeal anesthesia. The foreign bodies consisted of 7 alkaline battery, 4 root canal reamerpin, 1 guide-pin, 1 coin, 1 game coin, 1 spring-coil and 1 meat block in a case of esophageal stenosis. As to the instruments, GIF-P3 and GIF-XQ small caliber frontal view feiber scopes, magnet foreign body forceps for alkaline battery, polypectomy snare for root canal reamer and guide-pin, W-shaped foreign body forceps for coin were used. The indications for removal of foreign bodies from the esophagus and stomach are risk of perforation, toxicity and hemorrhage. As is mentioned above upper GI endoscopy to pediatric patients is very useful for removal of foreign bodies.

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Endoscopic biopsy under direct vision of gastrofiberscope made it possible to diagnose the gastric cancers in the early stage. Even by this method, however, it is still difficult to determine the exact extent and depth of involvement of gastric cancer. Therefore, in order to diagnose early gastric cancers more exactly, many new endoscopic procedures such as chromoendoscopy, laser endoscopy, endoscopic ultrasonography were developed. Furthermore, new endoscopic procedures for treatment of early gastric cancers such as injections of ethanol or anti-cancer agents, endoscopic polypectomy and endoscopic treatment using laser light were developed. These new endoscopic techniques and tools may bring about good results in more early detection and complete cure of early gastric cancers. In the present paper, the development and/or improvement of endoscopic procedures for endoscopic diagnosis and treatment of early gastric cancers in our hospital are reviewed. The following results are obtained; A) Advances in endoscopic diagnosis of early gas-tric cancers 1. According to the gross characteristic finding of the tumor, we subdivided early gastric cancers of type I into molar and non-molar types, and that of type IIc into tumors with and without converging folds. This macroscopic classification of early gastric cancers was very useful for diagnosis of depth of involvement of the tumors and determination of the target sites of endoscopic biopsy. Since 1961, 1, 500 cases of early gastric cancers were found in our hospital. Mucosal cancers, cancers located in the upper portion of the stomach and small cancers less than 10 mm in the longest diameter were found in increasing frequencies. 2. Endoscopic television and electronic endoscopy made it posible to simultaneously observe the same endoscopic pictures by many endoscopists, and so make accurate diagnosis. Image processing enhanced the ability to discriminate gastric lesions. 3. Chromoendoscopic examinations (Congo red test and Congo red-methylene blue test) developed in our hospital were useful for diagnosis of the extent of early gastric cancers. By the latter test, gastric cancers were observed as areas where both dyes were bleached. 4. New endoscopic procedures using laser light and FITC-labeled monoclonal antibody may be useful for early detection of gastric cancers. 5. Infrared laser angiography was useful for discriminating between the mucosal and submucosal cancers. B) Advances in endoscopic therapy of early gastric cancers 1. Topical injections of absolute ethanol was effective in the treatment of the elevated types of early gastric cancers, although recovery of the specimens was impossible. 2. Photodynamic therapy using hematoporphyrin derivatives and dye laser irradiation was a useful method for treating depressed type of early gastric cancers, especially ulcerated types of the tumor untreatable by the other endoscopic therapies In summary, these tests developed in our hospital permit more accurate detection of suspicious lesions in the early stage, and so the early cancers can be completely cured by the endoscopic treatments.

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