Hematoporphyrin derivative (HpD) has an affinity to malignant tissue and shows cytocidal effects when it is excited by Argon-dye laser (630nm). This method is called Photodynamic Therapy (PDT). Effects of PDT on esophageal cancer were discussed in this stydy. The study on the concentration of HpD in cancer cells and the histopathological study on the effects of laser beam penetration showed that the most reasonable condition to treat intramucosal cancer was to be irradiated by Argon-dye laser 48 hours after injection of HpD with a power of 300 mW for 5 minutes per 1 cm square. Under this condition, PDT has been performed on 7 cases of superficial esophageal cancer. All cases were followed periodically by endoscopy with bite biopsy for 9 months to 44 months and no cases have any local recurrence. So it is concluded that we think PDT is one of very effective therapy in the treatment of superficial esophageal cancer which cannot be treated by any surgical procedure because of the severe complication, and the best indication of PDT of esophageal cancer as radical treatment is for the cancer within mucosa, that is, superficial flat type and most of the superficial errosive type by an endoscopic diagnosis.

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We studied the diagnosis of lymph node metastasis surrounding the esophagus on the cases of esophageal cancer with endoscopic ultrasonography (EUS). The result were as follows ; 1) Limiting the diameter of lymph nodes over 5 mm, the visualization rate was 47.5% with conventional EUS. While, that was 66.7% using enhanced EUS with oral load of oil in water type emulsion. 2) With the enhanced EUS, the accuracy of diagnosis of lymph node metastasis was 87.0%. 3) We made diagnostic criteria for the enhanced EUS. And the correlation between the size and shape of resected lymph nodes and metastasis was integrated with the criteria, which rose the accuracy of diagnosis up to 91.3%.

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Diagnostic studies were made on the lymph node metastasis surrounding the gastric wall in the cases of gastric cancer by the use of endoscopic ultrasonography (EUS) after the oral administration of 10% oil-in-water-type emulsion. The result were as follows ; 1) The most suitable time of the administration of 10% o/w type emulsion was thought to be two or three hours before EUS. 2) The ultrasonographic visualization rate of lymph nodes surrounding the gastric wall was 69% in the size of over 3 mm in diameter and 76% in the size of over 5 mm in diameter. 3) Lymph nodes which had no metastasis histologically were visualized with echoenhancement at its margin and inside after the administration of the emulsion. On the other hand, metastatic lymph nedes showed no enhancement in spite of administration of the emulsion. In the diagnosis of lymph node metastasis by EUS after administration of the emulsion, sensitivity was 92%, specificity 100%, false negative 0.04% false positive 0% in the lymph nodes of over 3mm in diameter. And while, sensitivity was 91%, specificity 100%, false negative 0.07%, false positive 0% in those of over 5mm in diameter. EUS is thought to be very useful in the diagnosis of lymph nodes metastasis surrounding the gastric wall by using 10% oil-in-water- type-emulsion, despite some problems are still remained to be solved.

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As a new functional endoscopic examination, we developed a new method of measureing the gastric mucosal electrical impedance using endoscope. In this study, the changes of the gastric mucosal impedance were evaluated in several gastric mucosal lesions. METHOD: 1) For the basic study, the levels of gastric mucosal impedance in rats and dogs were measured by the 2-electrodes method. 2) Clinically, the levels of it were examined by the 1-electrode method through endoscope in 63 patients with gastric mucosal lesions and normal controls. RESULTS: 1) With the 2-electrodes method on the stomach of rats and dogs, gastric mucosal impedance as the Cole-Cole plots was detected correctly. 2) Correct Cole-Cole plots in the gastric mucosa of the patients was also detectable with endoscope. In the measurement of the frequency at the zero point of the reactance (f (X = 0)) in the mucosas of esophagus, stomach and duodenum, significant difference between the frequency of the esophagus and that of gastro-duodenum was observed. Cole-Cole plots of the patient with gastric cancer was clearly different from that of the controls. Frequency at the zero of the reactance (f (X=0)) in the cancer patient (10.1±1.2 kHz) decreased significantly as compared to that in the controls (14.7±2.7 kHz). The range of R (X=0), |Z| in the patients with gastric cancer was also lower as compared to that in normal controls. In the study of the cancer patient, the range of f (X =0) did not show remarkable changes between the cancer lesions and the surroundings. But the range of R (X =0) in the cancer lesion dropped significantly against that in the surroundings. These results seem to indicate that the measurement of mucosal impedance was very useful in the diagnosis of the gastric cancer clinically.

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The Second Department of Pathology, Kurume University School of Medicine. Gastric biopsy was performed in 10, 743 patients from 1977 to 1983 in our service and 1, 108 (10.3%) cases of gastric carcinoma were found. Of the carcinomas, 120 (10.8%) were endoscopically diagnosed as benign lesion rather than malignancy. About half of them were diagnosed as gastric ulcer and the rest half were as erosion, gastritis or polyp. Gastric carcinomas misdiagnosed as benign ulcer had no relation to their histological types, but 24 lesions of 27 misdiagnosed as erosion or gastritis were histologically differentiated type of carcinomas. Clinically twenty-three (2.1%) of 1, 108 carcinomas had a negative result for cancer at the initial biopsy. In these false negative cases, 7 of 11 advanced cancers were macroscopically Borrmann II lesions and 6 of them were differentiated adenocarcinomas. Eight of 9 early carcinomas had depressed lesions and there were no predilection for their histological type. Three cases endoscopically diagnosed as benign lesion had a negative result for cancer at the initial biopsy. In our studies, 0.27% of carcinoma cases had double false negative results for cancer by both of macroscopic and microscopic examinations. Endoscopists were classified into three groups according to their experience, 1) expert, 2 freshmen, 3) others, and a comparison of the groups was done concerning the risk of misdiagnosis. The risk of the double false negative of expert group was 0.06% and that of freshmen group was 0.95%. There was a significant difference between the two groups (p<0.001). Nowadays the technique of gastric biopsy is safe and widely adopted with great accuracy in the diagnosis of gastric cancer. However, our studies conclude that the ability to make a precise clinical diagnosis is more important for endoscopist.

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Endoscopic morphological features of submucosal tumors of the lower GI tract were studied with our eighteen cases, reviewing the literatures in Japan. The contents of our cases were showed as Table 1. The large intestinal lesions were covered with the smooth mucosa, so they could be diagnosed relatively easily as submucosal tumors. Rectal carcinoid tumors were revealed to be yellowish sessile protruded lesions (Figure 1). They were felt hard by "palpation" with the biopsy forceps and their tumor tissues were obtained frequently by ordinary bioptic procedure. Lymphangiomas were identified as whitish sessile soft elevated lesions (Figure 3-a). After biopsy, transparent fluid came out from the tumors and the tumors diminished in size (Figure 3-b). Lipomas were yellowish soft tumors. Two of them were pedunculated lesions and one of them was a large sessile lesion with a small ulceration (Figure 4-a, 4-b). Leiomyomas were sessile hard elevated lesions. One out of two cases had a central depression (Figure 5). Hemangiomas were recognized in a case of blue rubber bleb nevus syndrome and appeared red-brownish mulberry-shaped or hemispherical lesions. One of them became smaller in size after bleeding episode (Figure 6). Both of the two cases of terminal ileum were associated with intussusception. They were regarded as epithelial tumors or malignant lymphomas, because of their reddish granulated appearance and diffuse ulceration (Figure 3-c, 3-d, 4-c, 4-d). From the above results, it was considered that the lesions of the large intestine could be made qualitative diagnosis of endoscopic observation in detail taking account of the knowledge from litaratures (Table 2, 3). But in the cases of the terminal ileum, it was difficult to recognize even as submucosal tumor.

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The study was carried out to elucidate endoscopical differences between two types of early colonic cancer with adenoma (no-D type) and so-called de novo type (D type). In each group endoscopical observations were correlationed with pathological findings. In the present study, de novo type cancer was defined as early colonic cancer without histological evidence of adenoma. MATERIALS : 98 cases (104 lesions) of early colonic cancers resected by polypectomy or laparotomy from 1972 to 1985 at Kitasato University Hospital were studied. RESULTS: 1) D type cancers were 17.3% of all early colonic cancers. 2) There was no difference in ages, locations and sizes between the two groups. 3) One-third of the D type showed excavated lesions. On the other hand, most of the non-D type were seen as the protruded type. 4) The surface of the protruded lesions of the D type lacked the normal appearance, and was seen as muddy or erosion. That of the non-D type showed the characteristics of the adenoma in the adjacent resion, so called "adenomatous pattern by magnifying-endoscopical classification". We concluded that it was possible to differentiate endoscopically the D type and non-D type cancers.

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We evaluated the effectiveness and safety of a new multipolar electrocoagulation method "BICAP" in both experimental and clinical studies. The "BICAP" method was emplyoed in 14 cases with upper GI massive bleeding, including 9 cases of gastric ulcer, a case of gastric polyp, 2 cases of duodenal ulcer, a case of Dieulafoy ulcer in the duodenum and a case of gastric cancer. We were able to stop bleeding in 13 out of 14 cases. No rebleeding and complications were experienced. "BICAP" method was designed to keep advantage of conventional bipolar electrocoagulation and neglecting disadvantage of monopolar coagulation. It was concluded that "BICAP" method proved to be a safe and effective way of the treatment of upper GI bleeding.

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Endoscopic ultrasonographic findings of three patients with generalized or segmental type of adenomyomatosis of the gallbladder were compared with those of four patients with chronic cholecystitis.The main part of the wall thickness of adenomyomatosis of the gallbladder was in the second low echoic layer, whereas that of chronic cholecystitis was in the third high echoic layer ; these endoscopic ultrasonographic findings were in agreement with the thickened muscular layer and subserosal layer, respectively.Small cystic echos occasionally containing a fine high echo spot were seen in the second low echoic layer in the patients with adenomyomatosis of the gallbladder. These findings were consistent with dilated Rokitansky-Aschof f sinus and intramural stone. The border between the second and third layer was wavy in the patients with adenomyomatosis of the gallbladder, whereas that in chronic cholecystitis was relatively clear.This result suggests that adenomyomatosis of the gallbladder can be diagnosed qualitatively on the basis of endoscopic ultrasonographic findings.

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One hundred and twenty-two duodenal ulcer patients at a scarred stage were followed endoscopically over one year and recurrence of ulcer was studied with special reference to the endoscopic features of ulcer scar. Results obtained were as follows : 1) A recurrence rate was 53.3%. The mean age in recurrent group was 44.6±13.5 years, while 46.6 ± 11.6 years in non-recurrent group. 2) A recurrence rate at stage S1 was 88.6%, while 32.0% at stage S2. There was significant difference between both groups. 3) Duodenal ulcer scars with central depression or marginal elevation tended to recur. The recurrence rate was 90.9% in cases with marked central depression or marginal elevation. In non-recurrent group, improvement of the grade of central depression was found in 26.3%. 4) No relationship was found between the grade of fold convergence and recurrence rate. These results show that it is important to give anti-ulcer drugs to become S2 scar and that a close follow-up study by endoscopy is necessary in cases with central depression or marginal elevation.

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12 patients with Crohn's disease suffering for more than five years were investigated concerning the changes of colonic lesions by X-ray and endoscopic examinations. The results obtained were as follows. 1. When the medical treatment was effective, multiple small ulcers and aphthoid ulcers disappeared and changed to a localized cobblestone appearance. 2. Cobblestone appearance, which were recognized on the initial study, improved to coarse inflammatory polyps. However, some of them exacerbated to dense inflammatory polyposis with a stenosis. 3. Longitudinal ulcers which were found on the initial study, remained unchanged for a long period, or altered to an eccentric deformity. 4. These results suggested that the early lesions of the large intestine were multiple small ulcers and aphthoid ulcers.

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In October 1981, a 43-year-old man, who had undergone a partial gastrectomy with Billroth II reconstruction for duodenal ulcer 19 years before, came to our hospital with a sense of upper abdominal fullness. Roentgenogram and endoscopic examination revealed a protruded lesion on the large curvature of the anastomosis site. In January 1982, reoperation of the remnant stomach was performed. Macroscopically, the surgical specimen showed a massive, serpiginous, circumferential stomal polyp with prominent gastric areas on the surface at the anastomosis site. Microscopically, the stomal polyp showed hyperplasia of young foveolar epithelium, pseudopyloric-gland metaplasia and cystic dilatation of the gastric glands. These features were diagnosed as "Stomal polypoid hypertrophic gastritis (SPHG)" proposed by Koga et al. or "Gastritis cystica polyposa" (GCP) described by Littler et al. Arising in the SPHG on the large curvature, there was a well differentiated tubulal adenocarcinoma. The tumor, 2×2×3 cm in size, extended down to the deep proper muscle and was limited to the remnant stomach.

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A case of primary sclerosing cholangitis associated with cholecystolithiasis is reported. A 64-year-old female was admitted with complaints of fever, jaundice and general fatigue in August, 1985. Ultrasonography and abdominal computerized tomography revealed a stone in the gallbladder. Her laboratory data suggested mild obstructive liver dysfunction. Anti-DNA, anti-nuclear and anti-mitochondrial antibodies were all negative. The serum ceruloplasmin level was slightly elevated. At operation for cholecystolithiasis, cholangiography showed irregular patterns of the choledocal wall and dilatation of the left hepatic duct. Postoperative endoscopic retrograde cholangiography demonstrated charac-teristic "beaded appearance", "prunned tree appearance" and "diverticulum-like outpouchings" in the intra-and extrahepatic biliary ducts. Hepatic biopsy demonstrated cell infiltration in the periductal area and marginal ductular proliferation. These cholangiographic features and histologic findings led to the diagnosis of primary sclerosing cholangitis. It had been generally accepted that primary sclerosing cholangitis associated with biliary calculi was not included in the category of primary sclerosing cholangitis. During recent 20 years, however, many authors have recognized that primary sclerosing cholangitis with gallbladder stones is also included in the classical one.

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A 24-year-old male operated on for perianal abscess one year earlier was admitted to Meitetsu Hospital in April 1983, complaining of diarrhea, right lower abdominal pain and a palpable mass. Upper GI series showed a stenosis and multiple polypoid lesions of the duodenum. Barium enema revealed longitudinal ulcerations and a stenosis of the terminal ileum. A biopsy specimen obtained from an area near the ileocecal junction revealed non-caseating granuloma. From these findings, the patient was diagnosed as having Crohn's disease of the duodenum, ileum and colon. The patient responded well to prednisolone and was discharged in September 1983. However, six months later, he was re-admitted with a relapse of the right lower abdominal pain. After treatment with elemental diet (ED), his symptoms disappeared, and he was discharged in August 1984. Since then he has remained on per os ED therapy and has kept well. Six cases of gastroduodenal Crohn's disease previously reported in Japan, were treated surgically. We, however, suggest that patients with gastroduodenal Crohn's disease can be treated conservatively with careful follow-up.

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Ectopic gastric mucosa was found in the duodenum of four patients. The first was a 74-year-old man who had multiple nodules without erosion or ulceration involving the duodenal bulb and proximal second portion. The second was a 50-year-old woman who had multiple nodules without erosion or ulceration involving the duodenal bulb. The third was a 68-year-old man who had a semipedunculated polyp with central ulceration located on the posterior wall of the bulb. The forth was a 50-year-old woman who had an irregular solitary polypoid lesion with erosion located on the anterior wall of the duodenal bulb. Biopsy specimens of the duodenal polypoid lesions showed gastric mucosa composed of gastric epitheliums and gastric fundic glands with chief cells and parietal cells in all four cases. In the former two cases with multiple nodules, it was thought of congenital heterotopic gastric mucosa because biopsy specimens showed a great amount of gastric mucosa with complete gastric fundic glands and epithelium. In the latter two cases with solitary polypoid lesion, it was suspected of metaplasia at the healing stage of ulceration and erosion because islets of ectopic gastric mucosa were seen in the duodenal mucosa.

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The patient was a 27-year-old man with intermittent vomiting, abdominal pain and eruption of 5 years' duration. Laboratory data on admission showed hypoproteinemia and leukocytosis without eosinophilia. Roentgenographic examination of the small intestine revealed an edematous change and multiple protruded lesions at the mesentric site of the distal ileum. Laparotomy demonstrated severe edema and thickened wall in the distal ileum, and the affected ileum was then resected. Histologically, marked hypertrophy of muscular layer with diffuse infiltration of eosinophils was found and eosinophilic enteritis was diagnosed. In 7 years after the operation, eosinophilic enteritis recurred three times and improved each time with corticosteroid.

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Two cases of non-specific small intestinal ulcer were reported. First case was a 58 years old man who was admitted to our hospital on September 1980, with chief complaint of pain in the epigastrium and right lower abdomen. He had a past history of leucoderma, lung tuberculosis and iridocyclitis. G-I x-ray examination disclosed an irregular ulcer in the terminal ileum adjacent to the ileocecal valve. The resected specimen showed two deep ulcers with the surrounding edematous, granular and elevated mucosa and three ulcer scars in the terminal ileum. Diagnosis of non-specific ulcer was confirmed histologically. Five years later, the re-operation was performed for a large ulcer which developed in the stoma. However, two months after the operation, barium enema and colonoscopy revealed a deep ulcer in the small intestine proximal to the anastomosis. The second case was 44 years old male who was hospitalized on July 1985, complaining of melena. He had a past history of easy fatigability and stomatitis for 13 years and occurred melena twice on November 1982 and November 1983, respectively. X-ray examination of the small intestine revealed horseshoe-shaped deep ulcer with the converging folds in the ileum. Three active ulcers (Ul-IV) and two ulcer scars (Ul-III) were found in the ileum 170 cm proximal to ileocecal valve in the resected specimen. Histologically, it was proved to be benign non-specific ulcerations with severe pyloric metaplasia.

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