We performed endoscopic ultrasonography (EUS) in 46 cases which had been suspected of gastric or esophageal submucosal tumor by X-ray and endoscopic examination. EUS demonstrated that 36 cases were true submucosal tumors and 10 cases were oppressive lesions caused by the tumor or the organs outside the stomach or esophagus. Among the 36 cases of submucosal tumor, there were 28 myogenic tumors, 4 aberrant pancreases, 3 lipomas, 1 gastric cyst. In order to distinguish submucosal tumor from oppressive lesion, it is important to clarify the layer structures of the gastric or esophageal wall at the portion of the tumor by EUS. A method considered possible was to diagnose the nature of the submucosal tumor by observation of the depth of intra-mural lesion and of its echo patterns. In cases of myogenic tumor, it was difficult to distinguish leiomyoma from leiomyosar-coma by echo patterns, but it was useful to observe the diameter of the tumors. In all 3 cases of leiomyosarcoma, the diameters were more than 4 cm, and on the other hand, the internal echo or the irregularity of the edge of the tumor did not always correlate to malignancy of the myogenic tumor. A distinctive feature of the internal echo patterns of aberrant pancreas were as follows :(1) The echo level of the tumor was higher than myogenic tumor, and slightly lower than lipoma. (2) There were scattered low ecgo spots in its echo of the tumor. It was difficult to distinguish submucosal tumor from oppressive lesion by X-ray or endoscopic examination, but it was not so difficult to distinguish these two lesions by EUS and it was also possible to evaluate the quality of these lesions by EUS. In conclusion, EUS was found to be very useful to differentiate the diagnosis of elevated lesions of the upper gestrointestinal tract.

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The endoscopic examination was performed in 136 patients at Tokyo University Hospital and endoscopic biopsy specimens were obtained from both the greater curvature of the middle body and the lesser curvature of the middle antrum, processed for both histologic examination and pepsinogen I (PG I), pepsinogen II (PG II) measurement. The concentrations of PG I and PG II in 1 mg wet weight of the mucosa were determined by radioimmunoassays as reported previously (Clip. Chim. Acta 122 : 61 and 126: 85, 1982). The results were obtained as follows: 1) Compared with the endoscopically normal cases (n: 34), the PG I and PG I levels of the mucosa in gastric ulcer cases (n: 40) showed slightly lower values but there were no significant differences between the two groups. In the duodenal ulcer cases (n: 26), there was a significantly high value of the PG I level of corpus mucosa (CPG I) and a tendency of high values both in the PG II level of corpus mucosa (CPG II) and the PG II level of antral mucosa (APG II). In gastric carcinoma cases (n: 18), there were significantly low values both in the levels of CPG I and CPG II, and a tendency of low value in the level of APG II. 2) Both levels of mucosa PG I and PG II decreased gradually according to the progress or severity of both the atrophic gastritis and intestinal metaplasia.

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A follow-up study was made for one year or more after complete endoscopical healing of 142 duodenal ulcer patients. The recurrence was found in 47.9% within one year. The endoscopical manifestation (solitaly, kissing or linear) was unable to predict recurrence of the ulcer. Seventy point six persent of the patients had a hyperpepsinogenemia 1 in endoscopically recurrent ulcer group, and 77.0% had a normopepsinogenemia 1 in endoscopically non-recurrent ulcer group, and the difference of serum pepsinogen 1 level was statistically significant between recurrent and non-recurrent ulcer group (p<0.01). It was concluded in this study that determination of the serum pepsinogen 1 level is useful for the prediction of recurrence of duodenal ulcer.

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To overcome the limitations of sonography or laparoscopy for abdominal disease, the use of laparoscopic sonography was investigated. The instruments used were a prototype equipment manufactured by Olympus Optical Co., Tokyo, Japan. In the present study, most of the cases were examined by the third prototype, Olympus LPS UMl/EUM1 unit. The transducer used was 10 MHz, 7 mm in diameter. A total of 183 cases were examined on 105 occasions. The advantage of the method is its ability to visualize occult lesions in undermined the liver, i, e., cysts, tumors, various benign focal hyperplasia and parasitic or inflammatory granuloma. Comparison between resected specimen and sonograms obtained by laparoscopic sonography revealed differences in internal reflectivity of haemangiomata, offering findings useful in the distinction of hepatocellular carcinoma and benign focal hyperplasias.

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Among the subjects of gastric ulcer (106 cases) and duodenal ulcer (69 cases), analysis was made on the alteration or time course of endoscopic findings and relapse under maintenance therapy for one year. Also, histological review of the biopsy has been made. As a result, endoscopic cumulative recurrence rate (one year) was 57.5% with gastric ulcer and 60.9% with duodenal ulcer. Whereas, about 70% of relapsed cases showed asymptomatic recurrence, and also, the group of asymptomatic recurrence showed clearly smaller and shallower ulcer than in symptomatic group, thus it was considered to be the effect of maintenance therapy. In the analysis of the background, the relapse of gastric ulcer was greatly affected by compliance, cigaret habit and size of ulcer. The relapse of duodenal ulcer was also greatly affected by the history of ulcer and compliance. In the analysis of endoscopic findings, all the relapsed gastric ulcer was due to the occurrence of red scar. However, the transfer rate to white scar from red scar in non-relapse cases in one year was 51.1%. In comparison to the ulcer in the usual healing process, the ulcer showing protruded healing process in the cases to which histamine H2 receptor antagonist were given, is definitly greater in size at the start of treatment. However, there was no difference in the relapse rate, therefore it is difficult to estimate the relapse by endoscopic pictures.

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As development of an isolated culture method of campylobacter jejuni, an importance of this bacillus as a pathogen of enterocolitis has been pointed out by many investigaters. We had 48 cases of campylobacter colitis from May 1982 to April 1985, and investigated their colonoscopic findings and clinical features. 29 cases underwent colonoscopic examinations, of which the entire colon and rectum were observed in 24 cases. There were only three cases without any abnormality (10.3%), while in the remaining 26 cases (89.4%) such abnormalities as redness, erosion, ulceration, etc. were observed. A rate of abnormal findings on each part was as follows : 31.0% in the rectum, 72.2% in the sigmoid colon, 50% in the descending colon, 30.8% in the transeverse colon, 24.1% in the ascending colon and 62.5% at the Bauchin valve, thus scoring a high rate in the sigmoid colon and at the Bauchin valve. The findings at the Bauchin valve were very interesting. They were acute active ulcers (10 cases) and regional redness like ulcer scar (5 cases). These ulcers were relatively large and irregular in shape, with sharp margins. No specific histopathological findings were observed. Main subjective symptoms were watery diarrhea, abdominal pain and fever. Melena was found in only one case.

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Ten patients of campylobacter colitis were examined endoscopically and histologically. Nine of them were male and the other was female. Mean age of them was 24.0. They complained of abdominal pain, fever, diarrhea and/or bloody discharge. Campylobacter fetus ss. jejuni was isolated from all of their stools by Skirrow's medium. Total colonoscopy was performed to the all patients but one (the second case). The mucosa from rectum to the right colon, was edematous and erythematous with scattered normal appearances. The characteristic feature was the ulcer on the ileocecal valve. This ulcer has never been reported in other acute colitis nor chronic colitis such as ulcerative colitis or Crohn's disease. Colonic biopsies were taken from all patients. The mucosa was edematous and infiltrated by acute and chronic inflammatory cells frequently with crypt abscess. Generally, depletion of goblet cells was minimal and crypt architecture was normal. Biopsies from the ulcer on the ileocecal vale, revealed nonspecific changes. It is not so difficult to diagnose colonoscopically as campylobacter colitis, seeing the characteristic ulcer on the ileocecal valve.

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The combined method using both EO (ethanolamine oleate) and polidocanol (Aethoxysklerol®) in the endoscopic variceal sclerotherapy (EVS) (EO-P method, Figure 1) was studied. Merits and demerits of this method were as follows. Merits 1) This method does not require any other special equipments as well as the fluolo-scopic apparatus. 2) Thus, the limitation is very few in terms of the number of assistants and equip-ments. Therefore, the sclerotherapy is easily performed anytime using this method. 3) There are several complications of this treatment, however the lethal one rerely occurs. 4) Agents of EO and polidocanol can make up for their demerits each other. Demerits 1) The less information about the morphology of varices can be obtained in this method than in the EOMA method. 2) It is impossible objectively to find the optimal dose of injected EO.

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Recently, the relationship between group III lesions (the Japanese grouping system) and so-called borderline lesions (gastric adenoma, IIa subtype, atypical epithelium, etc) has become a new problem. Since its deveropment in 1983, we have applied a new jumbo biopsy technic"strip biopsy" to 60 lesions of group III. Using this method, 41 of 60 group III lesions (68.3%) were pathologically diagnosed as gastric adenoma, but 18 (30%) were diagnosed as early gastric cancer. 78.3% of the gastric adenoma cases (including the depressed type and the flat type) were completely resected by strip biopsy. It seems that "strip biopsy" is very useful in diagnosis and therapy for gastric adenoma.

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Balloon catheter dilatation was attempted for treatment of biliary tract strictures. Various sizes of the RIGIFLEX Balloon Catheter (Microvasive Co.) were used, and two approaches, transhepatic and transpapillary roots, were selected in this study. The technique was successfully accomplished in 12 patients without any complications. The procedure was effective in 10 patients with benign stricture, but not effective in 2 patients with malignant stenosis. There have been no restenosis of the lesions in follow-up observations of these patients. Balloon catheter dilatation is a simple, safe, effective and economical alternative to other conventional methods in the treatment of benign stenosis of the biliary tract.

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One case of sever esophagal moniliasis assacioted with acute myelocytic leukemia (AML) is reported. A 16 year old boy suffered from with complication of esophageal moniliasis. Endoscopic findings, 20 days after the onset of AML, showed scattered shallow ulcers with yellowish coating. The ulcers rapidly grew larger and deeper to occupy the whole esophagus, and were accompanied with massive bleeding. Soon after remission of AML, the endoscopic findings of moniriasis disappeared and ulcers were no longer recognized. But severe stenosis was formed in the lower esophagus, and, at the same time, mucosal bridge and many pseudo-diverticula appeared in the middle part of the esophogus. Massive bleeding in acute stage and esophageal stenosis in healing stage are typical complication of severe type of esophageal moniriasis. However formation of mucosal bridge in the esophagus is very uncommon in the literature.

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This report describes a case of esophageal hemangioma for which endoscopic polypectomy was performed. An 82-year-old male complained of difficulty in swallowing and discomfort of the throat. Roentgenograf is examination of the esophagus revealed an ovoid shaped mass, 2 cm in length with irregular surface at the lower esophagus. Esophagoscopy revealed a pedunculated tumor that was located just above the esophagogastric junction. This tumor was covered with normal mucosa and the coloration of the surface mucosa was not altered. An endoscopic polypectomy was performed for this tumor. After comfirming hemostasis at the stump, the endoscope was pulled out from the esophagus. The excised specimen measured 18×11×8 mm. This was elastic soft and the cross section was spongy containing a small amount of blood. Pathohistrogically this tumor was a capillary hemangioma. In the literature, 32 cases of esophageal hemangioma were reported previously in Japan excluding our case. An attempt was made to classify these hemangioma into three types.

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This case report describes a patient with esophageal retention cyst. A 77-year-old man was admitted to our hospital on December 15th, 1985 for further evaluation of a protruded lesion of the esophagus. On gastrointestinal roentgenogram, a smooth surfaced semi-pedunclated protruded lesion was recognized in the lower esophagus (Figure 1). Endoscopical examination of the esophagus showed a smooth surfaced, semi-pedunclated submucosal tumor at 39 cm from the incisors. The tumor was soft and 1.6 cm in diameter (Figure 2). The endoscopical diagnosis was a cystic lesion such as cyst or lymphangioma. Polypectomy was performed and the submucosal lesion was removed completely. The specimen measured 1.5×1.6×1.0 cm and was a cystic lesion filled with clear fluid (Figure 3, 4). Histological diagnosis of the specimen was a retention cyst of the esophagus (Figure 5, 6). Only 3 cases of esophageal retention cyst including our case have been reported so far in Japan (Table 1).

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This case report describes two patients of gastric leiomyoblastoma. The first case was a 54-year-old female who was admitted because of an abnormality on upper gastrointestinal series in a mass survey. Endoscopic examination showed a submucosal tumor with a central ulceration in the posterior wall of the gastric body. Biopsy specimens taken from the central ulceration and the artificial ulceration by the injection of pure ethanol were negative for malignancy. The second case was a 77-year-old female who was admitted because of vomiting. Since stool examination for occult blood was positive, endoscopy was performed. Endoscopic examination showed a submucosal tumor with a central ulceration in the posterior wall of the gastric body. Biopsy specimens taken from the central ulceration were negative for malignancy. In these two cases, CT showed that metastatic lesion was absent and the tumors grew intramurally. On laparotomy, frozen specimens showed leiomyoblastoma and wedge resection was performed. Endoscopic ultrasonography performed in the second case showed that the tumor was originated from smooth muscle and the internal echo of the tumor was uneven. Endoscopic ultrasonography may be a useful procedure which gives an information regarding the nature and location of a submucosal tumor before operation.

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A 67-year-old woman was admitted to our hospital for precise examination of a right orbital and maxillary sinus tumor. Gastroendoscopic examination revealed three regularly shaped, white-coated ulcers in the angulus and antrum. Ten days after initial endoscopy, the ulcers increased in size and irregular protrution of the surrounding mucosa was observed as an orbital tumor developed. The diagnosis of Wegener's granulomatosis was made by biopsies of the orbital tumor and stomach. Using prednisolone and azathioprine, the orbital tumor decreased in size and the irregular surrounding mucosa of gastric ulcers was found to have disappeared when endoscophc examination was done again. Four months on treatment, the patient became increasingly weak with anorexia, and developed tarry stools. Endoscopy revealed a giant ulcer. On the great culvature of the stomach. Doses of prednisolone and azathioprine were increased and resulted in rapid improvement of her clinical symptoms. The incidence of gastrointestinal involvement is low in Wegener's granulomatosis. There have been few reports of gastric lesions in this disease observed endoscopically over a long period of time. This report describes endoscopic findings of varied gastric changes in Wegener's granulomatosis.

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A 53-year-old male was referred to our hospital with a complaint of left hypochondralgia. ERCP was performed because of elevated serum amylase and CA 19-9 levels. The main pancreatic duct was tapered and obstructed at its tail, and lack of the branches and a pooling of the contrast medium were also observed. On angiography, no major vessels showed obvious abnormalities, but there was a finding of encasement involving a part of pancreatic magna artery. Caudal pancreatectomy was carried out uneventfully and the histological study confirmed the existance of a tomor in the tail, 1.3×1.0×1.0 cm in size, localized within the parenchyma of the pancreas with no evidence of metastasis. Thirteen cases of small carcinomas (T1) of the tail of the pancreas including ours were reviewed literally. All cases in which laboratory tests were reported showed elevated serum and/or urine amylase levels and abnormal changes in the main pancreatic duct on ERCP. To improve the rate of resectability and prognosis of the cancer of the pancreas tail, synthetical assessment of amylase, tumor markers, US, CT, ERCP, angiography and so on would be important considering the possibility of this disease.

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A case of confluence stone with multiple'gallbladder stones was presented which was diagnosed and treated by percutaneous trashepatic cholangioscopy (PTCS). Cholecystectomy was considered to be un necessary because the gallbladder changed into 3.5×1.8 cm in size which was communicated with the bile duct through the dilated cystic duct after removing all stones.

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A 49-year-old man was admitted to our hospital with melena. Endoscopically, massive bleeding was noted from the top of a bluish elevated lesion in the second portion of the duodenum, which was regarded as duodenal varix (Figure 1). The bleeding could be stopped by injection of pure ethanol into the lesion (Figure 2). Fourteen days after the injection, laparotomy was performed because of the rebleeding. The lesion was resected and it was proved to be an isolated duodenal varix histologically (Figure 3, 4). Angiogram, abdominal CT, abdominal US and other examinations were performed after laparotomy, but there was no evidence of portal hypertension (Figure 5, 6) and any other varices. Therefore, this varix probably represents a congenital vascular malformation. Ninety seven cases have been reported about duodenal varices since the first report of Alberti in 1931 (Table 2), but most of them were due to portal hypertension (Table 3). Only 3 cases which was thought due to vascular malformation has been reported.

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Hemostasis and cure were achieved by endoscopic local injection of pure ethanol (ETH) into 4 lesions in 3 patients suspected by emergency endoscopy to, have exulceratio simplex (Dieulafoy). The patients were 49-and 61-year-old males and a 74- year-old female, all exhibiting hematemesis and melena. Emergency endoscopy revealed arterial hemorrhage in the anterior wall of the lesser curvature immediately below the cardia in the first patient, and in the posterior wall in the middle gastric body in the last two. Hemostasis was achieved in all patients by immediate local injection of ETH. The third patient showed melena again due to arterial hemorrhage of the posterior wall of the lower gastric body, and hemostasis was made also by local injection of ETH. Dieulaf oy's ulcer was formerly considered to be rare, but there have been 123 reported cases in Japan including the author's own patients. This disorder is frequently seen in males in their 40's to 60's with a male-female ratio of 3 :1. The lesion, most often involving the posterior wall of the middle to upper gastric bodies, were mostly Ul II, and the mean diameters of the exposed blood vessels and ulcer were 1.3 mm and 5.5 × 7.5 mm, respectively. Nearly all patients showed hematemesis and/or melena, and the hemorrhage was massive in 86% of the cases, of which 82% showed signs of shock. Diagnosis was made by endoscopy in 79% of the patients, but the site of the hemorrhage could not be often indentif ied. Surgery used to be regarded as the best and only effective treatment for Dieulafoy's ulcer, but endoscopic hemostasis is achived with increasing frequency due to recent technological developments of endoscopy. In the 54 patients reported, satisfactory hemostasis was achieved by local injection of ETH or hypertonic saline epinephrine solution (HS-E). However the effect of high frequency electric coagulation was not consistent. These results suggest that local injection of ETH or HS-E should be the first choice in endoscopic treatment of Dieulafoy's ulcer.

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A case of idiopathic portal hypertension associated with peliosis hepatis was reported. A 19-year-old man was admitted to our hospital with a compliant of general fatigue. On peritoneoscopic examination, the liver surface appeared undulant without nodule formation. Peliosis hepatis was observed diffusely on the surface of the liver (by chance). The pressure of the portal vein was 365mmH2O. In histology, moderate fibrosis connecting the central vein to the portal triad was observed with no pseudolobule formation. Simultaneously, an amorphous blood filled space without lining was observed. The findings were interpreted as idiopathic portal hypertension associated witg peliosis hepatis. To our knowledge, such patient has not been reported in Japan. It was thought that in the present case, peliosis hepatis ensued by increased pressure of the sinusoid or presinusoid following increased portal hypertension.

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A 70-year-old woman, who was found to have liver dysfunction and an elevated AFP level, was referred to our hospital. Laboratory data showed elevated serum transaminase activities and impaired ICG excretion. The serum AFP level was elevated to 333 ng/ml and CEA level was 4.0 ng/ml. She also showed positive stool occult blood (Table 1). Laparoscopy revealed a small hemispherical tumor protruded on the right lobe of the liver. A diagnosis of hepatocellular carcinoma was confirmed by guided needle biopsy (Figure 1). Ultrasonography, CT and angiography, however, failed to detect this tumor because of its small size and subdiaphragmatic localization. On the other hand, upper GI series and endoscopy revealed a IIc+IIa type early gastric cancer on the posterior wall of the antrum (Figure 4, 5). Right partial lobectomy of the liver and curative operation for the gastric cancer were performed. The resected specimen of the liver showed a small encapsulated tumor measuring 18×18 mm in diameter. Histology showed Edmondson III hepatocellular carcinoma with hepatic cirrhosis. Gastric lesion revealed a IIa+IIc type early gastric cancer and disclosed moderately differenciated adenocarcinoma of medullary type involving the mucosal layer without lymph node metastasis (Figure 6). AFP level returned to normal and no recurrence was observed 11 months after operation. This is a rare case of small hepatocellular carcinoma simultaneously associated with early gastric cancer, occurring in a female patient diagnosed preoperatively by laparoscopy, although other diagnostic methods failed to elucidate its location.

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