A retrospective study was attempted to know a diagnostic yield of visualization of the larynx and hypopharynx at the time of routine upper gastrointestinal endoscopy. Among consecutive 17, 388 endoscopies, 41 lesions were found in the larynx and hypopharynx. The incidence of abnormalities was 0.24%. Twenty-eight of the 41 lesions were benign. Thirteen lesions (10 patients) were diagnosed to be malignant. Hypopharyngeal cancer and laryngeal cancer were detected in 7 and 1 patients, respectively. The remaining 2 patients had a lesion of hypopharyngeal invasion of esophageal cancer. Five of 8 patients with hypopharyngeal and laryngeal cancer had synchronous or metachronous cancer (2 patients with laryngeal cancer, 2 patients with esophageal cancer, l patient with rectal cancer and primary hepatoma). Although all of the 10 patients with malignant lesion were symptomatic, barium meal X-ray did not reveal any abnormalitis in 5 patients. We recommend to draw attention to routine observation of the larynx and hypopharynx at the time of upper gastrointestinal endoscopy.

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From 1977 through 1985, 227 patient were examined by PTCS. Fifty patient with distal bile duct stenosis were picked up and PTCS findings were studied. PTCS findings were classified as redness, intra-biliary protrusion (granular, papillary, nodular protrusion on the bile duct wall), tumor vessels (small vessels running tortuously, diameter not uniform), distortion (bile duct distorted) and extra-biliary compression (bile duct wall is compressed from the outside). In bile duct carcinoma and papilla Varter carcinoma, redness, nodular or papillary protrusions, tumor vessels were observed at the stenotic part of the bile duct by PTCS in all cases but distortion, extra-biliary compression were not observed and diagnosed histologically by cholangioscopic biopsies in all cases. In pancreatic carcinoma, redness, intra-biliary protrusion and tumor vessels were observed in 93%, 71%, 68% and distortion, extra-biliary compression were also observed in 68%, 96% at the stenotic part of the bile duct. Cancer was positive in endoscopic biopsies in 79%. In chronic pancreatitis, intra-biliary protrusion, tumor vessels were not observed but redness, distortion and extra-biliary compression were observed at the stenotic part of the bile duct in all cases. In benign stricture of the bile duct, redness, nodular protrusion were seen but tumor vessels, distortion and extra-biliary compression were not observed at the stenotic part of the bile duct. From these findings, we can conclude that tumor vessels are those of carcinoma, and distortion and extra-biliary compression are findings of pancreatic lesion influencing the bile duct. So we can make the differential diagnosis of bile duct carcinoma (papilla Vater carcinoma) from benign stricture of the bile duct by the PTCS findings of tumor vessels observed or not and from pancreas lesion by the findings of distortion and extra-biliary compression not observed or observed. A pancreatic lesion is able to divide pancreas carcinoma from pancreatitis by the findings of tumor vessels observed or not. The differential diagnosis of pancreatic carcinoma from pancreatitis is difficult even by using PTCS, if the bile duct stenosis can not be seen by the endoscope for the bile duct too much distorted or compressed from the outside and/or if pancreatic carcinoma does not invade the bile duct.

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Two hundred thirty four cases out of 5000 ERCP examinations showed, abnormal findings of ERCP which were compartible with chronic pancreatitis by Japanese Society of Gastroenterology in 1983. Twenty three cases with pancreatic calculus, 20 cases with pseudocyst formation, 16 cases with irregularity of the main pancreatic duct and 3 cases with obstruction of the main pancreatic duct were diagnosed as positive findings of chronic pancreatitis. In 179 cases with suggestive findings, dilatation of the main pancreatic duct was most common and observed in 135 cases. Pancreatic calculus and pseudocyst formation were more likely associated with alcoholic patient. On the other hand, dilatation and irregularity of the main pancreatic duct were more frequently observed in patient with choledocholithiasis.

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The GF-10 (Olympus)-side-viewing type endoscope- was used as a panendoscope for 108 cases and compared ability of observation for several parts of upper G.I. tract with that of GIF-P₂, P₃-forward-viewing type endoscope for 211 cases. All cases did not have remarkable deformity and organic lesion in upper G. I. tract. In middle esophagus, EC junction, greater curvature of gastric body, prepylorus of the stomach and duodenal bulb, where it seemed difficult to observe with side-viewing type endoscope, ability of observation with GF-10 was almost same as forward-viewing type endoscopes. On the contrary, GF-10 was superior to forward-viewing type endoscopes in duodenal 2nd portion. For 644 cases who did not have remarkable lesion in the esophagus, GF-10 was inserted easily to duodenal bulb in 95.3% cases, and to duodenal 2nd portion in 85.7% cases. Then we examined 393 cases with GF-10 and 419 cases with a thin forward-viewing type endoscope who were recommended to take close examination after mass screening of upper G. I. series. In gastric body, more gastric ulcer scar cases were found with GF-10 than with a thin forward-viewing type endoscope. No significant difference was found between these endoscopes in ability to detect ulceration and polyps in other portions, though more polyps were found with GF-10. These results suggest that GF-10 is available as a panendoscope, and may detect more cases of minute lesion than thin forward-viewing type endoscopes.

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Endoscopic sclerosing therapy of esophageal varices using 5% ethanolamine oleate as a sclerosant was performed in 27 patients with liver cirrhosis. In 7 cases, the varices and esophageal tissues around them became necrotic and finally fell into the esophageal canal after the sclerosing therapy. In these cases, relatively large amounts of sclerosant had been correctly injected into the varicose veins. Several days following the injections, turbid white-yellowish elevated lesions were found on the oral portion of the injection along the varices. They were desquamated within 2 weeks and the varices on the oral portion disappeared. In 2 cases, the lesions were taken biopsies. Histologically, the varices and small blood vessels around them were completely occluded by thrombus. The esophageal tissue around the varices became degenerative and necrotic. In the followed up study, the curative eradication effects of the esophageal varices continued for a much longer time in cases showing desquamation than in the cases showing simple thrombosis without desquamation. It is thus evident that necrosis and desquamation of the esophageal varices following sclerosing therapy are important for the eradication or disappearance of the varices. The precise mechanism for desquamation of the varices still remains to be determined.

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The evaluation of color plays an important role in the endoscopic diagnosis. Analysis of color of the gastric mucosa was performed by the Lab color system of the images from the electron endoscope through the image processor. Firstly, we investigated the relationship between the distance (x) of lens-object and numbers of pixels (y) of sampling images from a disk sized 5mm in diameter. The regression equation was log y=4.39-0.041x. Secondly, a white disk similar to the JIS9.0N having almost the same polar coordinates (32.18±0.41mm, 22.66±0.19degree ; mean±SD) seated in the gastric mucosa which was positioned in the center of the endoscopic monitor was used as a standard color in this system. There were no significant changes in the chromatic difference but the psychometric lightness (L) and the chromaticity coodinates were altered by changing the distance of lens-object. These findings suggested a possibility of the numerical evaluation of the color difference between a white disk and the endoscopic appearance of gastric lesions using this analysis and decision figure of color deviation. Analysis of eight patients with gastric cancer demonstrated that the hue and chroma differences of well differenciated adenocarcinoma were more reddish and vivid than those of poorly differenciated adenocarcinoma.

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Between January 1970 and April 1987, we treated 186 cases of early gastric cancer. Twelve among 186 cases (6.45%) had early gastric cancer associated with primary malignant neoplasms of the other tissues or organs, and they were determined as multiple primary malignant disease according to the criteria of Warren and Gates. The patients with multiple primary malignant disease were significantly older than the patients with earely gastric cancer only (mean age : 69.9 y.o. vs 61.6 y.o. ; p<0.01) and 10 patients were male (male : female =5:1). Eight patients had lesions that were diagnosed simultaneously and 4 patients had lesions that were diagnosed at intervals of more than one year. Four of 12 patients (33.3%) associated with esophageal cancer and 8 of 15 lesions of the associated malignant neoplasms (53.3%) occurred in digestive organs. Their prognosis was dependent on that of the associated malignant neoplasms. Fiveyear survival rate was 16.7 per cent and the average survival period was 22.7 months. The case of early gastric cancer associated with primary malignant neoplasms is not so common, but their prognosis may become very bad when accompanied with other malignant neoplasms. Therefore, treating with old patients of early gastric cancer, the other organs, especially digestive tract, should be precisely examined.

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Aberrant pancreas of upper gastrointestinal tracts was evaluated with endoscopic ultrasonography (EUS). The subjects were two cases of aberrant pancreas in stomach and one in duodenal bulb. In all cases, aberrant pancreas were detected clearly. The findings of EUS were as follows : (1) Aberrant pancreas were detected as a mass in the submucosal layer (third layer) of stomach or duodenum. (2) The echo pattern was solid with some small cystic or ductulous less-echoic areas. (3) In one case of aberrant pancreas in stomach, the proper muscle layer (the fourth layer) surrounding the mass was thickened. It is considered that the finding (1) is compatible with aberrant pancreas and the findings (2) and (3) are characteristic with aberrant pancreas. In conclusion, when these EUS findings are seen in submucosal tumor, it will be able to diagnose that the tumor is most probably to be an aberrant pancreas.

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To determine the significance of manometric pressure of the pancreatic duct in patients with alcoholic (ALCP), gall stone induuced (GSP) and idiopathic chronic pancreatitis (ICP), a microtransducer was inserted through a duodenoscope to measure pressures in the papillary sphincter zone (SO) and pancreatic main duct (PP) in 20 controls and 38 patients with chronic pancreatitis including 10 cases of ALCP, 7 cases of GSP along with papillitis and 21 cases of ICP. The pancreatic main ductal pressure was significantly higher in the patients with ALCP (55.7±28.9 mmHg), GSP (33.6±16.2 mmHg), or ICP (44.5±25.8 mmHg) than in the controls (16.2±8.7 mmHg), but there was no significant difference between ALCP, GSP and ICP. There was no significant difference between control subjects and ICP in the motility of SO. In ICP there were no correlation between PP and the motility of SO. In ALCP and GSP, the frequency of the papillary sphincter waves was significantly higher than in normal subjcts and there was a correlation between the PP and the motility of So. These data suggest that increased pancreatic ductal pressure in GSP with papillitis or ALCP may be partly due to papillary dysfunction, but not in ICP.

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A case of gastric syphilis confirmed by demonstration of Treponema pallidum as well as granulomatous change from biopsy specimen was reported. A 26-year-old male with a chief complaint of epigastric pain was admitted to our hospital with a suspicion of Borrmann IV gastric cancer. X-ray examination revealed rigidity of the wall and poor distensibility of the lumen from the lower part of the gastric body to the pyloric antrum. Endoscopic examination demonstrated various-sized, numerous protuberances and irregular shallow erosions with marked friability in the abnormal area detected by X-ray examination. Abdominal CT showed remarkable thickening of the walls in the lower half of the stomach. A granuloma consisting of several Langhans giant cells was found and no malignancy was demonstrated in the gastric biopsy specimen. In addition to these findings, a diagnosis of gastric syphilis was strongly suspected from positive serologic test for syphilis. A diagnosis of gastric syphilis was confirmed by the demonstration of Treponema pallidum by silver staining and electron microscopic examination of biopsy specimen. Antibiotic treatment was administered. The symptoms were improved a few days later, and X-ray and endoscopic abnormalities almost disappeared approximately two months later.

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A 75-year-old woman admitted to our hospital complainting purpura at lower extremities and arthralgia. The diagnosis of S-H purpura was confirmed by biopsies of the skin and the kidney. On the fifth hospital day she suffered from abdominal pain with melena. Endoscopic examination of the upper GI tract and the colon revealed purpura like lesions in the stomach and hemorrhagic erosions in the colon. In Japan GI tract lesions in patients with S-H purpura have been reported in 32 cases including the auther's case they were varied from purpura like lesions to ulcer and were seen all over from the stomach to the colon. The purpura like lesions were reported in 5 cases in the stomach, 3 cases in the duodenum and 9 cases in the colon.

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Hemorrhage into pancreatic pseudocyst is known as a rare but the most rapidly lethal complication of chronic pancreatitis. To the best of our knowledge, there is no report in the Japanese literature that pseudoaneurysm of the splenic artery was diagnosed with pulsed Doppler sonography. A 40-year-old male with a long history of alcohol abuse was admitted to our hospital because of severe epigastric pain with radiation to back on September 22, 1986. Physical examination showed an acutely ill man with hypertension ; 220 systolic, 140 diastolic. There was tenderness in uppear abdomen. No masses were palpable. Abdomen was flat and soft. Laboratory findings on admission revealed almost within normal limits except for elevated serum trypsin and elastase level (reported later). The patient was initially treated conservatively under suspected diagnosis of hemorrhage into pancreatic pseudocyst. On September 26, he developed agonizing pain again when he went to toilet. Computed tomography was taken three times at different day. CT showed an extremely characteristic findings of hemorrhage into pancreatic pseudocyst corresponding in timing to each phase of acute bleeding. Ultrasonography revealed a sonolucent mass in the tail of the pancreas. Pulsed Doppler US disclosed a turbulent arterial signal within this mass. Celiac angiography revealed pseudoaneurysm of the splenic artery. Hemobilia was observed by fiberoptic endoscopy. On the 6th days after admission, he underwent operation. Pancreatic pseudocyst with acute hemorrhage was found. Ligation of splenic artery, splenectomy and internal drainage in a form of Roux-Y anastomosis were carried out. He was discharged without further pain or bleeding.

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A 59-year-old man with mucin-producing pancreatic tumor is reported. In January 1973, he was first seen at this hospital because of occasional episodes of abdominal pain after drinking large amounts of alcohol, and a diagnosis of chronic pancreatitis was made. At that time ERCP findings showed a small pancreatic cyst at pancreatic body and a minute radiolucency in main pancreatic duct near the cyst. The second ERCP examination performed in June 1980 showed a dilatation of main pancreatic duct with amorphous filling defects at the body of pancreas, which was thought to be protein plugs. The third ERCP examination performed in November 1985 revealed a large cystic lesion at the pancreatic body and a remarkable dilatation of proximal main pancreatic duct with irregular filling defects. Endoscopic findings at the ERCP showed widely enlarged orifices of both major and minor papilla with retention of mucous material. Those characteristic findings led to the diagnosis of mucin-producing pancreatic tumor. The distal pancreatectomy was performed in May 1986. Histopathological examination revealed a papillaly adenoma with a size of 1.5×1cm in the cystic dilated main pancreatic duct.

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We experienced 2 cases of superficial and small liver cancer which were hard to detect. Although a superficial and small mass suggestive of liver cancer was found with ultrasonography in the liver, it was not detected with other diagnostic imaging methods. Biopsy of the mass was performed with a hemostatic material (GTXIII) for biopsy under laparoscopy and a superficial and small liver cancer was detected, which could be resected surgically. A male patient, aged 75 years, had a hepatoma, 1.4×1.3 cm in size, in the right anterior inferior segment and has survived about 4 years after biopsy and removal of the mass without recurrence. Other patient, a male aged 53, had a 1.6×1.6 cm hepatoma in the left lateral segment and has survived without recurrence for about 10 months after biopsy and removal of the mass. Bleeding hardly occurred during biopsy, and metastasis and dissemination were not seen clinically, so that GTXIII was considered to be useful material.

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Solitary juvenile polyp has long been regarded as benign lesion without malignant potential. The case herein reported concerns an elderly male with a duodenal solitary juvenile polyp containing foci of adenomatous epithelium. Such a case is extremely rare, so the case is worth reporting. A 77-year-old male visited the out-patient clinic of our hospital with further examination of anemia. Upper GI radiography showed a pedunculated polyp, 2.5×1.5 cm in size, in the 3rd portion of duodenum. Endoscopic findings showed the pedunculated polyp with smooth surface easy to bleed. The polyp was endoscopically excised and examined histopathologically. Histologic features of this solitary juvenile polyp showed mucus-filled cystic spaces with increased mucosal stroma branching of glands and numerous capillaries. In addition, adenomatous component with partial severe dysplasia was seen.

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Since Davis introduced lavage solution contained polyethylene glycol electrolyte solution in 1980, lavage solution technique for premedication in case of endoscopic and fluorescopic examination of the colon has been popular particularly in the Western countries. However, it is true that oral administration of polyethylene glycol electrolyte lavage solution (PEG-ELS) between 3, 000 and 4, 000 ml is absolutely necessary for getting a better lavage effect and this large dosage may trouble the patients. Therefore, we have tried to develop new PEG-ELS which show a better lavage effect even in a lesser dose, and the present study was planned to make sure the lavage effect of newly developed PEG-ELS. Sixty subjects ranging from 24 to 77 in age (54.1 in avarage) were used for evaluation. Concerning dosage of this lavage solution, avarage tolerable dose was 2, 782 ml and in the group tolerated to a dose between 2, 000 and 2, 500 ml a sufficient lavage effect was taken. In conclusion, newly developed PEG-ELS showed a sufficient lavage effect in lesser dosage- as compared with original PEB-ELS developed by Davis.

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Endoscopic polypectomy using high frequency electric current is popular today as a therapeutic measures of colorectal polyps and early cancers, but is technically difficult for flat and/or broad-based polyps. Surgical treatment is usually recommended for these lesions. Five cases of rectal polyp including two early cancers were treated safely by the heat probe method, a non-invasive endoscopic procedure developed for the treatment of upper GI bleeding. Between 210 and 300 joules was applied to the lesions, then polypoid lesions were completely disappeared forming cautarization ulcers. Ulcers healed within 3-6 weeks later. The heat probe method, the newest endoscopic hemostatic method, is not only effective and safe but technically easy. This method was considered effective for the treatment of flat elevated and broad-based colorectal lesions, which have been difficult to remove by the conventional endoscopic polypectomy. With the development of this method, more polyps and early cancers of the colon and rectum are expected to become the indication of endoscopic treatment.

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