The effect of biliary decompression and drainage duration in endoscopic biliary drainage (EBD) were estimated on differences of methods or tube diameter (nasobiliary drainage : NB-D, duodeno-biliary drainage by 7.2 Fr tube : S-DB, by 10 Fr tube : L-DB or by combination of plural tubes : C-DB). The serum bilirubin values after biliary decompression in patients with obstructive jaundice are expected to decrease on an exponential curve. The values before and after each period should appear as linear regression on scattergram, and this regression coefficient means a reduction rate of jaundice. The values of total bilirubin at one week interval following EBD were examined in 46 cases (14 of bile duct cancer, 9 of gallbladder cancer, 16 of pancreatic cancer, 6 of cancer of papilla of Vater and one of gastric cancer). The correlation and regression analyses were made between the values before and after each period determining a regression coefficient as a "jaundice reduction index" of each group. Effect of reducing jaundice was estimated by analysis of covariance on each index. As a control, 20 cases performed PTCD were also examined. Drainage duration of each drainage tube was estimated as the tube survial by Kaplan -Meier analysis and Generalized Wilcoxon analysis on 53 cases (17 of bile duct cancer, 10 of gallbladder cancer, 19 of pancreatic cancer, 6 of cancer of papilla of Vater and one of gastric cancer). "Jaundice reduction index" of each groups were N B - D = 0.6152, S - DB = 0.3596, L-DB = 0.2297 and PTCD = 0.6460. A statistically significant higher reduction rate was seen in L-DB and S-DB to PTCD, and also in L-DB to NB-D. On drainage duration, long term functioning of the endoprostheses was not always shown in a large bore tube, and the result was poor in C-DB. As the tube survival in a short duration tends to be recognized in the same patient, we attempted a modified study by mean value in the same drainage in the same patient. A tube survival of C-DB turned to be long and we considered that the duration is influenced by patient's factors rather than drainage methods or tube diameter. In conclusion, internal drainage is more effective than external drainage on reduction of jaundice, and large bore endoprostheses may have higher reduction of jaundice. But in maintaining the patency, there are no remarkable differences between drainage methods or tube diameter.

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One hundred and fifteen cases of endoscopically proven esophageal varices were treated with EIS involving 375 sessions at Taipei Municipal Jen-Ai Hospital from September 1983 to June 1986. The patients were treated with 5% ethanolamine oleate 6-8 ml (30 cases) or 2% sodium tetradecyl sulfate 2 ml (85 cases) in each varix. The technique we employed was the Takase's modified intravascular injection method.

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Introduction : Since 1979, endoscopic Nd-YAG laser therapy of the gastrointestinal neoplasms has been studied. There is no computer controlled Nd-YAG laser irradiation up to the present. Since 1984, we have been studying experimentaly the endoscopic local hyperthermia (laserthermia) with low power (less than 5 watts) Nd-YAG laser irradiation. In this paper, we reported the experimental data and the possibility of applying the endoscopic laserther-mia with the newly developed computer controlled system (Figure 3, 4, 5). Material and Methods : Under the thermal control within the therapeutic level about 43.0±0.5°c with the computer controlled laserthermia system, the thermal distribution on the mucosal surface in the canine stomach was measured with multithermocouples under laparotomy and gastrotomy (Figure 7, 8, 9, 10). Histological studies : Correlations between the distance of thermal control and his-tological effects in the canine stomach were studied. Soon after laserthermia, stomach was removed and studied histologically by hematoxylin and eosin staining (H & E). Results : (1) Thermal distribution (Figure 14) ; Tissue temperature was controlled nearly 43.0°c within an area from 10 mm in diameter at about 6 mm of the control distance. At about 9 mm of the control distance, tissue temperature was over 65°c (2) Control of tissue temperature ; It is possible to control tissue temperature stable for 20 min. with the computer controlled hyperthermia system. (3) Histological findings in the canine stomach ; Soon after laserthermia, mucosal edema and congestion, and submucosal intravascular coagulation were observed (Figure 15). Conclusions : Safe and adequate laserthermia became possible by the developoment of computer hyperthermia system. Effects of laserthermia were wider than those of the conventional laser irradiation, and may be due to thermal necrosis and intravascular thrombosis. Laserthermia can be applied to the endoscopic therapy of gastrointestinal neoplasms.

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Endoscopic ultrasonographic determination of stromal reaction was studied in 17 stomach cancer patients. Endoscopic ultrasonogram of 6 cases with medullary type of stromal reaction a showed low echo in 5 cases (83.3%), while 6 cases with scirrhous type showed a high echo in 5 cases (83.3%). These results suggest that the stromal reaction which correlated with type of metastasis in gastric cancer can be evaluated preoperatively by echoic pattern of endoscopic ultrasonography.

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The artificial gastric ulcers which are produced endoscopically by strip biopsy are UL-II in depth, and their healing process is thought to be a model of clinical acute gastric ulcers. In clinical and experimental (canine) studies, I week after ulcer formation, regener-ation epithelium maybe observed with dissecting microscope and magnifying endoscope. At the same time, the proliferative zone is enlarged at the ulcer's edge. After 2 weeks, the regeneration epithelium grows to a palisade-like appearance on endoscopical observation, and generative cells can be detected in the regeneration epithelium with the bromodeoxyur-idine (BrdUrd) labeling method. Using a laser measurement endoscope it was observed that the area of canine artificial gastric ulcers is uniformly reduced. In clinical cases, all artificial ulcers healed within 6 weeks. The 4-week cumulative healing rate is 50% in the non-H2 blocker group, 68.8% in the H2 blocker group and 75.5% in the combined group. It is suspected that a state of decreased acid secretion is also good for mucosal regeneration in normal stomach. In conclusion, moderate scaled UL-II clinical acute gastric ulcers are thought to heal within 6 weeks under ordinary anti-ulcer drug therapy.

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During the period 1976-1985, 16 patients with histologically proven colorectal non-epithelial tumor were experienced at the Third Department of Internal Medicine, Tohoku University Hospital. Eight patients had a colorectal lipoma. A diagnosis of lipoma was made easily by endoscopy in most of the cases of lipoma because they appeared yellowish and soft, while it was difficult to make the diagnosis of lipoma in two cases with a large and hard tumor. It was easy to make the diagnosis in all of 3 patients with colonic lymphagioma because the tumor was soft, wavy and watery, and it was also difficult in all of 3 cases of colorectal leiomyoma, one of them revealed leiomyoma coexisted with tubular adenoma in the same tumor. There were two cases of colorectal lymphoma, diagnosed by endoscopic observation as advanced cancer and amebic colitis, respectively.

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A 66-year-old woman visited our clinic with the complaint of epigastralgia, nausea, vomiting. Giant rugae and poorly dilated gastric wall from the fornix to the upper portion of the body were pointed out on the gastric radiological study, and then she was admitted for the closer examination. Laboratory data on admission showed marked eosinophilia (19%) in the peripheral blood and elevated serum IgE level (5, 200 U/ml), Endoscopic examination revealed fold thickening mainly in the major curvature of the gastric body, and endoscopic ultrasonography disclosed that these wall thickening was composed of the submucosal layer. The eosinophil count and serum IgE level decreased with the rapid improvement of the clinical symptom, and giant rugae disappeared soon after admission. Endoscopic gastric biopsies including "Jumbo biopsy" were performed 3 times during the admission, but no abnormal findingis such as eosinophil or malignant cell infiltration were observed in the obtained specimens. From the peculiar clinical findings, it was suspected that this case might have been a case of eosinophilic gastritis limited to the submucosal layer. Challenge tests were performed using several foods as antigen. However, no signs nor symptoms were represented. Though histological diagnosis was not obtained, this case is thought to be full of suggestion on speculating the etiology of giant rugae of the stomach.

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This case report describes a patient with macronodular liver complicated with drug-induced liver injury. A 37-years-old man complained chiefly of abdominal distension and adomitted to our hospital due to ascites, jaundice and hepatic disorder. Initial laparoscopy revealed that the liver showed smooth surface of hemispheric regenerative nodes and deep groove-like depressions, diagnosing as a so-called potato liver (Figure 5). Aggravation of hepatic reserve potential was obseved at the adomissoin. Histological findings indicated a slight chronic inactive hepatitis (Figure 6). During the clinical course, drug-induced liver injury was suddenly manifested. Laparoscopy after aggravation showed enlargement of regenerative nodes of the liver as compared with the initial laparoscopic findings. On the surface of the liver, marked lymph vesicles appeared and its color tone was green, but heterogenous. (Figure 8). Histological findings indicated chronic active hepatitis with lobular disorganization. (Fig-ure 9). In our case, etiology of potato liver was unclear. The findings, however, suggested that the major causative factors which rapidly aggravate to active hepatitis in our case may be not only the associated drug-induced liver injury but also involvement of immuno-responsiveness in a potato liver and imbalance of reproduction between the vascular and bile duct system at the regeneration of the liver.

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We presented a case of extreme hypoplasia of the left hepatic lobe diagnosed by laparoscopy. The patient was a 21-year-old man who was admitted to our hospital because of further evaluation for liver dysfunction. To confirm the histological diagnosis, laparoscopy was carried out. Laparoscopic appearance of the right hepatic lobe was compatible with chronic active hepatitis. But on the left side of falciform ligament, there was only a flattened remnant of the left hepatic lobe, and diagnosed as hypoplasia of left hepatic lobe. Histological findings of biopsied specimen from the right hepatic lobe showed chronic active hapatitis. The diagnosis of hypoplasia of the left hepatic lobe was confirmed by additional abdominal CT scanning and abdominal angiography findings.

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A 20-year-old male was admitted to our hospital with a complaint of fever. US revealed multiple cystic lesions in the posterior segment of the liver. Intravenous administration of antibiotics was effective to fever, but no morphological changes of the cystic lesions in the liver were observed by US during the clinical course. Therefore, Caroli's disease was strongly suspected. ERCP was done, and showed multiple cystic dilatation of the peripheral intrahepatic bile duct and small stones. Laparoscopy showed whitish network pattern on the smooth surface of the liver and typical findings of congenital hepatic fibrosis (CHF) was recognized histologically. The conception of Caroli's disease was in confusion. We therefore analyzed reported cases of Caroli's disease in Japan according to the classification by Saito et al (Table 2). Most of cases were demonstrated multiple cystic dilatation of the peripheral intrahepatic bile duct (IIIcm) and they were closely related to CHF and renal cystic lesion. Considering these results, we reviewed Japanese literatures about IIIcm (Table 3). Chief complaints in most of cases were fever and/or pain due to inflammation of the biliary tract, but relatively few cases had gallstones. There were few cases associated with varices. It seemed that US was very useful to make a preliminaly diagnosis, but to make the essence of this syndrome clear, precise evaluation especially by ERCP, histological examination of the liver and renal examination were indispensable.

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A male of 56-years-old with past history of diabetes mellitus and pancreatolithiasis had four episodes of melena in 1981, 1982, 1985 and 1986. He was admitted to our hospital with the chief complaint of upper abdominal pain. Laboratory data on admittion revealed anemia. Endoscopy for the upper digestive tract showed bleeding from the duodenal papilla. Pancreatic juice collected by selective cannulation method, pancreatogram obtained by ERCP and finding of CT showed that the bleeding had originated in a pancreatic cyst accompanied by chronic pancreatitis. Resection of body and tail of the pancreas and the splenectomy were performed. Serial sections of the resected specimen revealed the bleeding from a pancreatic branch of the lienal artery. Pathologically the pancreatic cyst was retention cyst. Fiberscopy of the descending portion of the duodenum may sometimes reveal, the source of the bleeding which is uncommon and difficult to identify.

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We report 5 cases of adenoma of the papilla Vater, including one case consisting of adenoma and carcinoma. They are 4 male and 1 female, ranging in age from 50 to 80 years. Chief complaints in 4 cases were epigastralgia, itching, icterus and loss of weight, respectively, and in the remaining 1 patient the adenoma was found incidentally by routine upper GI check up for liver cirrhosis. Endoscopic findings showed tumor of the papilla in 3 cases and swelling of the papilla Vater in other 2 cases. Endoscopic biopsy was done in 4 patients. The histology was Group III in 3 cases and Group II in 1 case. ERCP findings showed tumor shadow at the end part of common bile duct in 2 cases, common bile duct stone in 1 case and no abnormality in the remaining 2 cases. No abnormal pancreatgram was found in any patient. Four cases were treated surgically ; pancreatoduodenectomy in 1 case and excision of the papilla Vater in 3 cases. Surgical intervention was not done in 1 patient for his associated disease. As the correct diagnosis of the tumor of papilla Vater is sometimes difficult even on biopsy for benign or malignant character, ERCP should be considered for correct diagnosis and therapy.

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A 49-year-old male was referred to our department with the chief complaint of epigastralgia. Ultrasonography showed the atrophic gallbladder and the existence of a tumorous lesion which included a strong echo with acoustic shadowing in its fundus. The border between the gallbladder and the liver was quite obscure, so direct invasion of the liver by malignant tumor could not be ruled out. ERCP also revealed a hemisphere-like filling defect with irregularity of the surrounding wall. CT and angiography showed it to be vascular-rich. We performed percutaneous transhepatic cholecystoscopy to determine if the lesion was malignant or not. Endoscopically, the tumor was seen to be covered with papillary mucosa. Proliferation of fine vessels which is usually considered to be a sign of malignancy in the neighboring mucosa was also observed. The lesion was 15×15×10 mm in size. Histologically, the protrusion was caused by an intramural gallstone and surrounding abscess, which spread into the liver parencyma.

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A 59-year-old man was admitted to our department with a complaint of upper abdominal discomfort. Endoscopically, there was an irregular ulceration just oral to the major papilla. It caused stenosis of the second portion of the duodenum and prevented the cannulation of the major papilla. The accessory papilla was slightly enlarged, and we could perform ERP through it. There were no abnormalities except for slight dilatation of the main pancreatic duct and the lack of connection between the ventral and dorsal pancreatic ductal systems. US and CT showed cystic dilatation of the Wirsung's duct. Based on these findings, we diagnosed this case as pancreas divisum accompanied by carcinoma of the papilla of Vater Surgical treatment was carried out. Histological study revealed the existence of pancreas divisum accompanied by carcinoma of the papilla of Vater. As far as we could find in the literature, this is only the third reported case in Japan.

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A case of cavernous hemangioma of duodenum with massive bleeding was experienced. A 72-year-old female was admitted because of melena. Endoscopic examination revealed a semipedunculated submucosal tumor with superficial erosions and bridging fold in the 2nd portion of the duodenum. It was considered to be a bleeding focus of frequent massive bleeding. Instead of surgical operation, endoscopic polypectomy was successfully performed with safety. The resected tumor was 19 × 14 × 5 mm in size and was histologically diagnosed as cavernous hemangioma. Hemangioma in the duodenum is very rare disease and only 5 cases including our case reported in Japan. This is the first case which has been resected by endoscopic polypectomy in Japan.

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We reported 7 cases of drug associated colitis with longitudinal ulcer which was observed with endoscopical examination. Male to female ratio was 5 to 2. Average age of patients was 41.6 years old. It was associated with bloody diarrhea with abdominal pain in most cases. In five cases, due to common cold, antibiotics was administered. In all cases, administration was done orally, three with Cefems, two with Penicillins, two with Cefems and Penicillins combined. Drug associated colitis developed one month after the termination of drug administration in three cases. However, it developed during drug administration in four cases. Five among seven cases were involved in the sigmoid and descending colon. Remaining two cases were involved up to the proximal colon and one of which accompanied terminal ileal lesion. Five out of six cases showed leukocytosis with positive CRP. In all cases, stool culture showed negative pathogenic microorganism and one out of three cases examined showed positive C. difficile toxin. Non-pseudomembranous case in drug associated colitis resembles closely to ischemic colitis of transient type so far as general clinical symptoms are concerned. Endoscopially it is not rare to show longitudinal ulcer similar to ischemic colitis and involvement of intestinal ischemia to the symptom is suggested.

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A 58-year-old man with clinical features of Cronkhite-Canada syndrome is reported. He was admitted to Shimada-city Hospital complaining anorexia, diarrhea and edema. Multiple polypoid lesions in the stomach, the duodenum and the colon were seen on endoscopy and skin pigmentation, alopecia and onychodystrophy were found on physical examination on admission. The symptoms and signs were improved in three months with hyperalimentation and administration of 40 mg of prednisolone per day. In a serial colonoscopic obserbation, however, three polyps remained in the sigmoid colon. The biopsy specimen of the largest one (17 mm in diameter) showed adenocarcinoma. Subsequently, sigmoidectomy was performed at a surgical department in our hospital. The adenocarcinoma invaded into the proper muscle layer with local lymphatic metastases histologically.

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Colonoscopy is sometimes very difficult when there exists a marked loop formation in the sigmoid colon. In order to keep the sigmoid colon in a straight position, the sliding tube is widely used. However, some disadvantages have been found in using the present sliding tube. There is some difficulty in handling the scope attached to the sliding tube, being restricted by the length of the scope. For the purpose of covering the demerits of the conventional sliding tube, a new sliding tube (jointed sliding tube, ST-CX) has been devised. ST-CX is made up of two parts ; an inner tube and on outer tube. Both tubes are fixed together during colonoscopy. Prior to the insertion of the scope, each tube is separetly attached to the scope and is placed near the handle. When the tip of the scope reachs the splenic flexure of the colon and the sigmoidal loop is let down, inner and outer tubes are jointed together. Then the sliding tube is inserted safely into the upper part of the descending colon as the same manner as the conventional sliding tube. Using the jointed sliding tube, the colonoscope is restricted only by the length of the inner tube. Therefore, ST-CX is also used by a short length colonoscope, which is more easily manipulated.

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