Since panendoscopy was introduced on upper gastrointestinal examination, reflux esophagitis has been frequently noticed. The early stage of reflux esophagitis has been observed and recorded since emergent endoscopy became popular. To clarify the pathogenesis of reflux esophagitis, especially that of the erosive and/or ulcerative type, clinical and endoscopical findings were investigated. Materials and method : One hundred and twenty three cases of erosive and/or ulcerative esophagitis were experienced from January 1982 to March 1986. They were devided into 6 groups according to sex (male or female) and age (under 39 years old, 40-59 years old, over 60 years old). Incidence of clinical symptoms (dysphagia, heartburn, abdominal pain and vomiting), cardiac insufficiency, association of peptic ulcer, favorite foods obtained through a questionnaire and combined diseases apart from peptic ulcer were studied and each result was compared with that of 2051 cases (control group) denied esophagitis endoscopically. During the above period, endoscopic follow-up study was made in 27 cases. Results : Patients with erosive and/or ulcerative esophagitis commonly complained dysphagia, heartburn or vomiting irrespective of age, whereas in the control groups the incidence of those symptoms decreased with age. The endoscopical cardiac insufficiency was frequently accompanied with erosive and/or ulcerative esophagitis in every age groups. Especially in male patients under 39 years old and from 40 to 59 years old, both mild and severe cardiac insufficiency were accompanied more frequently than control groups (P<0.05, P<0.05 for mild and P<0.01, P<0.01 for severe). Duodenal ulcers were more frequently noted in male under 39 years old and from 40 to 59 years old, and in female over 60 years old than in control groups (P <0.01, P <0.01, P <0.01). Gastric ulcers were also noted as frequent as duodenal ulcers in both male and female from 40 to 59 years old. In most of the cases, ulcers were in active stage. Among 27 cases followed-up endoscopically, 24 cases improved within two months and 1 case within three months. Two of 25 cases improved within three months showed recurred inflammation several times a year. Two of 27 cases did not improve within three months, and were associated with resistant peptic ulcers. Conclusion : Erosive and/or ulcerative esophagitis showed characteristic symptoms and clearly and significantly related to cardiac insufficiency, peptic ulcer and some favorites of the patients.

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Preoperative endoscopic ultrasonography (EUS) was performed in 25 patients with esophageal cancer, and the diagnostic ability of EUS as to the depth invasion and lymph node involvement were evaluated, based upon the histological findings of the resected specimen. The results were as follows ; (1) The accuracy of diagnosis for the infiltrating depth was 76.2% (16/21), in cases where EUS could be carried out over the tumor. (2) The visualization rate of lymph nodes surrounding the esophagus was 48.5% with conventional EUS, when limiting the diameter of lymph node over 5 mm, while that was 78.4% using an enhance method by oil-in-water emulsion administration (enhanced EUS). (3) By enhanced EUS, normal lymph nodes were visualized with echo enhancement at its margin and/or inside. On the other hand, metastatic lymph nodes showed no enhancement. In addition to these findings, the size and shape of lymph nodes were integrated and diagnostic criteria of lymph node metastasis for enhanced EUS were made. According to these criteria, the diagnostic accuracy of lymph node metastasis was 87.5%.

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Ninety four lesions diagnosed as group III and IV on bite biopsy specimens were evaluated on strip biopsy specimens. Seventy four were well differentiated adenocarcinoma, eight borderline lesions, and twelve adenomas. Seventy nine of these ninety four lesions were polypoid. These seventy nine lesions were composed of fifty nine cancers, eight borderline lesions, and twelve adenomas which were classified according to size for every five millimeters. The relationship between the maximum size of these lesions, the histological diagnosisusing strip biopsy, and the surface of these lesions which were classified nodular, divisional, smooth, and so on, were investigated. Consequently, the maximum diameter of the adenoma was found to be less than fifteen millimeters, and the surface was smooth regardless of the size. In the cases of cancer, the surface tended to be smooth in lesions less than five millimeters. But, as increase in the size, nodules and divisions tended to be formed on the surface, and the number of these nodules were inclined to become marked when these lesions were more than fifteen millimeters in diameter. Under five millimeters, both the surface of the elevated type of cancer and the adenoma tended to be smooth. But the color of the cancer tended to be reddish and the adenoma whitish. So, the color of the lesion was one impartant point of the differential diagnosis between the cancer and the adenoma under five millimeter in diameter.

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Purpose : Clinical usefulness of the peritoneoscopic observation of liver colored with indocyanine green (ICG) has been reported. However, why difference in distribution or local coloration occurs is not understood at all. The present study aims to clarify this point in relation to ligandin. Method : Distribution of ICG of liver surface observed by magnified peritoneoscope (30 min. after injection of 3mg/kg ICG) was compared with the distribution of ligandin in the direct-vision biopsy specimen stained by indirect peroxidase method using anti-ligandin antibody in 34 cases with chronic liver disease. Hepatic GST activities were also measured. Results: 1) Hepatic GST activity which reflects the amount of ligandin decreased with histological progress in chronic liver diseases. 2) Magnified peritoneoscopic observation of liver colored with ICG correlated very well to the lobular structure and also to the distribution of ligandin in the biopsy specimen. Particularly, the patchy markings, the peritoneoscopic finding of early regenerative nodule, were intensively colored with ICG, and ligandin was strongly stained in the aimed biopsy specimen from those patchy markings. Conclusions : These findings suggest that local ICG coloration reflects the change in the distribution or local amount of ligandin derived from the histological changes of liver.

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The etiology of Behcet's disease has not yet been elucidated. As superoxide has been reported to be overproduced in neutrophils of patients with Behçet's disease, we have tried to treat patients with intestinal Behcet's disease by oral administration of dl-α-tocopherol nicotinate (Vit E), anti-oxidative drug. Four cases of intestinal Behcet's disease had been followed-up for 17-51 months (mean 34 months) by medical treatment. Patients were 3 males and 1 female, with ages between 31-40 years, complaining of abdominal pain, melena, fever and diarrhea. They were given salicyl-azo-sulfapyridine combined with Vit E (1, 200 mg/day). Corticosteroid was not administered. Intestinal ulcer disappeared in 1 case and was markedly reduced in size in 3 cases, followed by clinical remission. These results suggest that medical treatment including Vit E should be considered first in patients with Behcet's disease except for cases in whom an emergency operation is needed for intestinal perforation or massive intestinal bleeding.

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We reported the usefulness of a high-frequency electrocoagulation hemostasis apparatus "BICAP". In this paper, we applied this apparatus for tumors of the upper digestive tract and good results were obtained. The subjects consisted of 1 patient with esophagostenosis due to advanced cancer, 4 with early gastric cancer, 5 with gastric adenoma and 6 with hyperplastic polyps. In patient with esophageal cancer, a specific bougie type probe was used to relieve the stenosis. In patients with early gastric cancer and adenoma, the probe previously used for hemostasis in the upper digestive tract was applied. After coagulation, endoscopic observation including biopsy was performed at appropri-ate interval. Of the patients with early gastric cancer, 2 patients were surgically operated after this therapy, and resected specimens showed no malignant findings on histological study. In the other patients who were followed after therapy, no evidence of recurrence was found on endoscopy or biopsy. Esophageal stenosis due to cancer, which was difficult to relieve using the conventional balloon or bougie, showed temporary improvement after treatment with the specific bougie type probe. Since the probe used in this method has 3 pairs of dipoles at equal intervals both on the tip and on the side, coagulation of lesions in the tangenital direction was also possible. In addition, water could be supplied from the center of the probe at an appropriate time, which allowed washing and cooling of the lesion. It was thought that the apparatus was useful for treatment at the bedside because of low cost, easy operation and portable.

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The same lesions in the rat stomach and colon were observed in order to compare the image of the electronic endoscope with that of the fiberoptic endoscope. After the endoscopic observation, the stomach and the colon were removed from the experimental animal, and stereo-microscopic observation and histological examination were performed to know the resolution of these two kinds of endoscopes. In the lesion-free gastric mucosa, the minute structure of the mucosal surface were observed with electronic endoscope, but not observed with f iberoptic endoscope. In water-immersion and restraint stress ulcer, immediately after the stress, the cobblestone-like mucosal redness could be seen with electronic endoscope. On the contrary, diffuse mucosal redness was seen with fiberoptic endoscope. In the observation of the hemorrhagic erosions following the mucosal redness, the inf ormations obtained using two systems did not show any difference. In acetic acid ulcer, the mucosal redness around the active ulcer was clearly observed with electronic endoscope and hardly observed with fiberoptic endoscope. In the observation of the regenerating mucosa around the healing ulcer, the images of two systems did not show any difference. In lesion-free colonic mucosa, the vessels in the mucosa and submucosa were clearly observed with both of those endoscopes, but the minute surface structure of the colonic mucosa could be observed only with electronic endoscope. In experimental colitis, irregularity of the vessels, interrption of the vessels and minute mucosal hemorrhage could be seen vividly with electronic endoscope, but not seen with f iberoptic endoscope. In this study, the image of electronic endoscope was superior to that of f iberoptic endoscope not only in the resolution of the minute structural changes but also in the resolution of color. And electronic endoscopy would be quite useful for observing the experimental gastrointes-tinal lesions which shows minute superficial mucosal change.

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Cholelithiasis, diagnosed during a period of 17 years from 1970 at our clinic by means of ERCP has amounted to 1986 cases. Of these patients with cholelithiasis only 10 or 0.6% were twenty years old or younger. Some clinical features in the young patients were noted in the followings. Male/female ratio was 1: 4. All of them had a chief complaint of abdominal pain. Concerning location of stones, they were found in the gall bladder in 5 cases or 50%, in the bile duct in 2 or 20% and in both parts in 3 or 30%. Among them 3 cases were known to be complicated with congenital choledochal cyst. Sole complaint of abdominal pain is occasionally complained at routine examination on young patients, especially on infants which usually embarrasses us in making proper judgement for the correct diagnosis. In addition, it has been described that cholelithiasis is scarcely seen among younger people, and because of this fact the disease in them has often been failed to be noticed. The clinical feature of abdominal pain is often seen as an initial chief complaint of the patients and in some cases choledocholithiasis and/or congenital choledochal cyst are found to be complicated with. It is to be emphasized, therefore, that in order to make sure of the diagnosis the combined method of abdominal ultrasonography and ERCP examination is an indispensable means for that purpose.

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A 22-year-old male was admitted to Kitasato University Hospital because of paralytic ileus due to SLE. One month after admission, he complained of severe odynophagia and poststernal pain, while treated with predonisolone. The endoscopy on 25th hospital day revealed multiple erosive lesions with raised, overhanging edges in the mid-lower esophagus. Biopsies of the erosive lesions revealed cytomegalic inclusions in nuclei and cytoplasm, mainly of vascular lining cells. An immunofluorescent study of the biopsied specimens disclosed cytomegalovirus (CMV) antigen in inclusions. We suspected that the etiology of esophagitis was ischemia due to vasculitis induced by CMV infection. Many postmortem cases of CMV esophagitis have been reported, endoscopically diagnosed cases are as few as 18 cases in European countries and 2 cases in Japan.

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We report 2 cases of gastric telangiectasia which were the cause of severe anemia. Case 1 was a 75-year-old man whose anemia was suspected pernicious anemia. Endoscopic examination showed numerous scattered, spotty or macular, flat or slightly elevated telangiectasia in the prepylorus. He was estimated to be a high risk patient for gastrectomy because he complicated liver cirrhosis. Local injection of pure ethanol improved his anemia remarkably. Case 2 is a 71-year-old woman who was treated as iron deficiency anemia. Endoscopic examination showed great numbers of telangiectasia in the antrum. Distal gastrectomy improved her anemia completely. In 2 cases there were no family history of telangiectasia and no telangiectasia were found in other organs. We could recognize vascular tufts without feeding artery and draining vein angiographically and dilated capillaries without abnormal vessels histologically. Our diagnosis was acquired angiodysplasia under the influence of arteriosclerosis as an underlying disease of gastric telangiectasia. Local injection of pure ethanol seems to be one of the effective therapy for inoperable cases.

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We report a rare case of ATL which grew in the stomach. Furthermore, ATLA-antibody and provirus were negative. A 60-year-old man born in Iwaki city visited to our hospital because of general fatigue, anorexia and emaciation. Roentogenographically diagnosed as gastric carcinoma (Borrmann type 4), he was admitted and endoscopic examination was performed. It revealed cobble-stone like lesions from middle corpus to antrum, although biopsy was negative. On admission, abnormal cells were not detected on peripheral blood. Treated by UFTM chemotherapy for a month, but was unsuccessful. Second endoscopic examination of the stomach revealed giant folds all over the stomach and malignant lymphoma was suspected. Biopsy studies supported these findings. Cells had OKT (3) & OKT (4) positive T helper/inducer character and ATLA antibody was negative. Furthermore provirus was negative on Southern-Blot method, too. Regarded as genome-negative ATL advocated by Shimoyama and his co-workers, the patient was treated by VEPA chemotherapy but ended in partial remission. Cobble-stone like lesions partially disappeared on gastroendoscopy after chemotherapy. There are 11 reports of the gastric lesions of ATL, large number of the cases have gastric ulcer and cobble-stone like lesions are secondly frequent. Almost all the cases demonstrated tumor cells. The contamined equipment or gastrof iberscope should be disinfected or sterilized according to the method of HBV's. Our case was interesting because of its gastric onset and genome negation.

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A 55-year-old woman visited a local physician in October, 1980 with chief complaints of epigastralgia, nausea and vomiting, which had started in June, 1980. The initial upper GI X-ray and endoscopic examination in October, 1980 revealed an irregular ulcerated lesion on the gastric angulus, which was suggestive of gastric cancer, but a biopsied specimen showed no malignancy. She recieved anti-ulcerative drugs, but her symptoms did not improve. In September, 1981, she visited our hospital for further examination of her gastric lesion. X-ray and endoscopic examination showed multiple irregular erosions from the antrum to the angulus, and a biopsied specimen revealed infiltration of mononuclear cells. The lesion was suspected to be reactive lymphoreticular hyperplasia (RLH). Conservative therapy using cimetidine was started, but the lesion did not heal. In December, 1983, her symptoms got worse, and the final endoscopic findings in January, 1984 showed rough and granular mucosa with multiple irregular erosions from the antrum to the lower body of the stomach. The lesion spread to the fundic gland area over the grandular border. Malignant lymphoma (superficial spreading type) was suspected. Subtotal gas-trectomy with R 2-lymphnodectomy was carried out in Febrary, 1984. Macroscopically, rough and granular mucosa with multiple erosions and some ulcer scars, which had a cobble stone-like appearance, was seen from the antrum to the lower body of the resected stomach. Histologically, the lesion was diagnosed as malignant lymphoma, follicular, predominantly small cleaved cells, which was limited to the submucosa. No lymphnode metastasis was seen. This case was followed up for three years and four months under the clinical diagnosis of RLH, and the final patho-histological diagnosis was malignant lymphoma. It is very difficult to differentiate RLH from malignant lymphoma by means of endoscopy and biopsy before operation. Early operation should be done when RLH is suspected.

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A 59-year-old woman, who was diagnosed of PBC (Scheuer II-III stage) 6 years ago and followed up without any symptoms, was admitted again to control DM. Laparoscopic and histlogical findings showed remarkable progression of PBC (Scheuer-IV stage), and ERCP showed abnormal findings of pancreatic duct. These abnormalities in pancreatic duct were not seen at the first admission, which suggested that these findings appeared in association with the progression of PBC. We speculated these lesions of pancreatic duct might be due to the same mechanism of PBC lesions in bile ducts. Laparoscopic findings, which showed the typical "rough bigger block" at the first admission, represented fine block formations diffusely. During the follow-up of this case, liver function tests have been stable, icterus has not been seen and itching has been diminished. Nevertheless, PBC lesion of this case progressed to complete liver cirrhosis. This case gave us some suggestion about the course of PBC progression.

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We experienced one patient with an infant's head-sized duodenal leiomyosarcoma showing extratubal development. The patient was a 72-year-old man who had sufferd from pain in the right hypochondorial region at onset of the condition. A mass about 10 cm in diameter was palpated in the right hypochondrial region. Roentgenographic examination of the upper digestive tract revealed an image similar to a submucosal tumor associated with a depression in the middle portion of the descending duodenal loop. Endoscopy revealed this central depression to be a fistula. Cytologocal feature of aspirated material by fisterography revealed spindle cells that were probably non-epithelial origin. The condition was diagnosed as a non-epithelial malignant tumor, and pancreatoduodenectomy was undertaken. The lesion was histologically confirmed to be leiomyosarcoma originated from the duodenum. There have been few reported cases of leiomyosarcoma of the duodenum associated with fistula. This present case was, therefore, considered to be an interesting one in which endoscopic f isterography and aspiration cytodiagnosis proved useful for the diagnosis.

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A case of annular pancreas in which the relationship between anuular pancreatic duct and pancreatic tissue was clarified by abdominal CT immediately performed after ERCP was reported. Sixty-six years old female was admitted to Akita Medical Center with a chief complaint of intermittent discomfort in the epigastrium for past two years. ERCP revealed annular pancreatic duct surrounding the second portion of the duodenum through cannulation from papilla of Vater. In addition, the relationship between annular pancreatic duct and pancreatic tissue with thickness of 1.2 cm was clarified by abdominal CT immediately performed after ERCP. No communication between annular pancreatic duct and dorsal pancreatic duct was confirmed through cannulations from both accesory papilla and papilla of Vater by the second ERCP. In addition to the case report, usefulness of abdominal CT immediately performed after ERCP for the diagnosis was discussed.

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Familial incidence of Crohn's disease reported in Europe and USA were about 10%, but only 10 case were reported in Japan. In this paper, we reported a siblings case, in one of which the lesions were found throughout the entire gut. The younger brother, 18 years old, had epigastralgia and loss of appetite from June 1983, and low grade fever from Augast. He had abdominal pains and tenesmus after meal from October, 1983. He had lost 12kg during 6 months. He was admitted to our hospital on December 1983. X-ray and endoscopic examination revealed segmental cobblestone appearance and longitudinal ulcers of the ileum and colon. Furthermore, endoscopic studies revealed small polipoid lesions, intramural fistura of the esophagus and cobblestone-like lesions in the duodenal bulb. Biopsy specimen of the anus showed diffuse granuloma-like inflamaatory infiltration in the mucosa and submucosa. The older brother was 23 year old. He had diarrheas and low grade fever from March 1981. X-ray examination of small intestine revealed longitudinal ulcers and cobblestone appearance. We analized HLA antigens in these siblings. The younger brother had A2, A9, BW46 and BW54, and the older brother had A9, AW33, BW54, B12 and C1.

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We experienced a case of chronic schistosomiasis japonica (SJ) which showed specific colonoendoscopic findings. A 69-year-old male admitted to our hospital because of hematuria due to chronic nephritis and was incidentally found to have liver abnormality (network pattern) by the ultrasonic study. Liver biopsy under laparoscopy revealed ova of SJ in the liver tissue. Barium enema examination showed the shortening of the sigmoid colon and the decreased numbers of haustration through out the colon. Atrophic mucosa with scattered yellow flecks was seen on colonoendoscopic examination, especially in the sigmoid colon, and, further, we could not see mucosal vessels clearly. By using magnified lens endoscopy, the yellow fleck was found to be consisted of many granules and the biopsy revealed that this yellow fleck was composed of numerous numbers of ova of SJ.

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Endoscopic injection sclerotherapy (EIS) with a transparent over-tube is very useful technique for bleeding or risky esophageal varices. However in the repeated EIS for the eradication of varices, there are some technical difficulties in injecting the sclerosant accurately into the small varices, and sometimes unexpected big ulcerations are made by the free hand tecnique. To make the EIS safer and more confirmed method, we have been trying to manage the small varices with the transparent over-tube under the negative pressure by the endoscopic suction pump. The small varix, which did not protrude through the slit of over -tube, will easily protrude and is fixed to the slit using the negative pressure in the tube. With this simple tecnique, we could perfom accurate intravariceal injection of 2-4m1 of 5% ethanolamine olerate (5% EO) to 8 patients, 29 small but risky varices without making any ulcerations. This method is easier and safer than the free hand technique, so EIS with transparent over-tube will be more popular and the endo-point of EIS will be clarified.

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