One hundred twenty patients with gastric ulcer and 61 patients with duodenal ulcer, who were followed endoscopically for a long term were studied on the clinical course of peptic ulcer, in paticular the relationship between scar stage and reccrrence, and the effects of maintenance treatment. After initial treatment, the rate of red scar (S₁) or white scar (S₂) formation from the active stage (A₁, A₂) and healing stage (H₁) was 97% for (S₁) and 3 % for (S₂) in gastric ulcer. It was 84% for (S₁) and 16% for (S₂) in duodenal ulcer. Recurrent rate was significantly higher in patients with red scars as compared with those with white scars. The transfer rate to white scar from red scar in the group on mainte-nance treatment was 59% for gastric ulcer and 61% for duodenal ulcer, significantly higher than in the group which discontinued treatment. Consequently, maintenance treatment was effective the rate of formation of white scars from red scars and also decreased the rate of recurrence of peptic ulcer. In the analysis of recurrence from white scars, there was no recurrence in the subjects on continuing drug treatment. Without maintenance treatment, recurrences occurred in all of patients, with gastric ulcers having linear white scars or with duodenal ulcers having depressed white scars. In subjects with doodenal ulcers healed by depressed white scars there was a significantly high recurrence rate compared with subjects with non-depressed scars. With regard to the influence of patients' habits, the recurrence of peptic ulcer was not greatly affected by alcohol, smoking, or coffee.

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A relationship between herpes zoster and upper gastrointestinal lesions was studied by gastroendoscopic examination on 122 consecutive patients in various stages of herpes zoster during the period from Jan. 1982 to Dec. 1988 at the Toho University Ohashi hospital. Of these, pathological endoscopic findings were noted in 108 cases (89%) including 119 gastric, 13 duodenal and 8 esophageal lesions. Endoscopic findings were evaluated in relation to their age, sex, period from the onset of skin rash to endoscopy, the site of skin lesions and kind of medication. Among patients under age 50-year-old, the incidence of gastric redness was significantly higher than that over age 51-year-old (p<0.05), whereas that of other lesions such as polyp, cancer, hyperplastic change was higher in elder group (p<0.01). No significant difference between sex ratio was recognized. In cases endoscopy was performed within 2 weeks from the onset of skin rash, gastric redness was more frequent than those examined after 2 weeks (p<0.01), whereas gastric erosions were more frequent in the later (p<0.05). In cases with herpes zoster located on chest or upper extremity, the incidence of gastric ulcer was higher than that located on other sites. In systemic herpes zoster, esophagitis was more frequently observed than in others. Two cases with herpes zoster on chest and one case on upper extrimity had gastric carcinoma. Before medical treatments, various lesions were recog-nized in the upper gastrointestinal tract. In cases treated by antivirus drug, incidence of normal finding was higher than that of other medicated groups. Valicella-zoster virus could not be detected in the biopsy materials from gastric ulcer or erosion. In conclusion, the upper gastrointestinal lesions with herpes zoster developed by after induction of stress, neurologic pain or some drugs. There was no evidence of the direct viral infection to induce the upper gastrointestinal lesions.

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Endoscopic injection sclerotherapy (EIS) has gained widespread popularity and a newly deviced transparent overtube (overtube) made EIS much easier and safer with its clear visual field even in acute bleeding cases. But it is quite difficult for small varices (Fl) to be performed EIS with an overtube, because small varices can not protrude into the lumen of an overtube through its slot. We work out the method which makes the tip of the overtube into a closed area with an inflated balloon fixed on a fiberoptic endoscope and makes the inside to be in a negative pressure state (NP-EIS). In this method under negative pressure control we can easily treat small varices (F1) equal to large varices (F3) and safety complete EIS with an overtube. The success rate of puncture of varices under negative pressure control became 100% (25 cases, 222 puncture sites) with no complications. So we think NP-EIS can solve the problem of usual method of EIS with an overtube. Under negative pressure control we can puncture any part of varices, so the rate of intravariceal injection becomes relatively high. As a result we confirm that NP-EIS must be a standard method of EIS with an over-tube for small varices.

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The role of gastric varices in upper gastrointestinal hemorrhage is still obscure. We studied the gastric varices in 40 patients with portal hypertension by endoscopy who had upper gastrointestinal hemorrhage. Among these 40 cases, bleeding sites were identified in 30 cases. Bleeding from gastric varices was found in 8 (20%). Bleeding from esophageal varices was found in 9 (22.5%) and from gastric ulcer in 9. This indicates gastric varices are one of the common sources of upper gastrointestinal hemorrhage in patients with portal hypertension. Regarding the location of the bleeding site of these 8 gastric varices, 4 cases bled from the varices located in the lesser curvature of the body close to cardia (Lc type), the other 4 cases bled from the varices in the fundus of the stomach (Lf type). Regarding the degree of the “Forms” of the bleeding gastric varices, they were severe (compatible with F₂-F₃ stage of the esophageal varices) in all these 8 cases. During the first week after hemorrhage, we could observe bleeding or adhesion of blood clots on gastric varices in 6 out of 8 cases. White coat and redness on gastric varices were also observed in all 8 cases. These findings were observed more than 4 weeks after the bleeding. Spontaneous hemostasis were obtained in 4 cases. Temporal hemostasis were obtained in the remaining 4 cases after balloon tamponade. We have tried the elective endoscopic injection sclerotherapy for esophageal varices in 4 cases after bleeding from Lc varices, no recurrent bleeding was found in these cases after a 4-12 months' observation. The general consensus should be made regarding the criteria on recording endoscopic findings of gastric varices as in esophageal varices.

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From September 1986 to November 1987, a study was conducted on 224 patients who had undergone endoscopic retrograde pancreatography (ERP). Changes in serum pancreatic enzymes were analyzed in order to determine a clinical basis for early diagnosis of post-ERP pancreatitis. The results are summarized as follows. 1. Out of 115 cases who had normal pancreatogram (normal group), 7 cases (6.1%) developed post-ERP pancreatitis, while of the 32 cases with chronic pancreatitis, 2 cases (6.3%) developed post-ERP pancreatitis. 2. In the normal group, there were significantly higher levels of serum pancreatic enzymes in the cases which developed post-ERP pancreatitis than those in the cases which did not (Figure 7, 8, 9). 3. Normal upper limit (NUL) were set by measuring the ratio of increase in serum pancreatic enzymes five hours after ERP in those cases in the normal group which did not develop post-ERP pancreatitis. With these NUL (value obtained by adding twice the standard deviation to the mean), diagnostic accuracy of post-ERP pancreatitis proved to be extremely high (over 95%) for all pancreatic enzymes included in the study (Table 2). 4. The NUL set for the normal group should also be applicable for diagnostic use in certain cases of chronic pancreatitis such as minimal change chronic pancreatitis and moderate change chronic pancreatitis. It is our opinion that the knowledge obtained from this study should improve the possibilities for early diagnosis and proper treatment of post-ERP pancreatitis, thereby, constituting an important step toward making ERP a safer diagnostic technique.

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During long time observations of post sclerotherapy of esophageal varices, recurrence of the varices has been observed even in the cases with complete disappearance. No recurrence of the varices was observed in the patients who had circular ulcer and cicatricial constriction in the lower part of esophagus. Therefore, a mucosa-fibrosing method by AS was performed in 20 patients making a circular ulcer in the lower part of esophagus and it showed good result. Chest pain and esophageal constriction were observed as complications. Chest pain improved spontaneously within 3-5 days while esophagectasis was needed in 36.4% of the patients. For esophagectasis, it was useful to insert a catheter with a balloon of 6cm in length prior to complete scarring of the circular ulcer. In adding mucosa-fibrosing method to EO-AS combination method, it seemed that the barrier against neogenesis of varix would be formed by fibrosis in esophageal mucosa and submucosal layers besides a full thrombosis of the blood supplying pathway.

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Two cases whose gastric biopsy specimens were mishandled were reported. Immuno-histochemical study using monoclonal antibody of blood group substances was performed and the mishandling of the biopsy specimens were proved. One of these two cases was endoscopically diagnosed as verrucous gastritis, but the histological report was gastric cancer. This reported diagnosis gave rise to a question for mishandling of the specimen, which was confirmed by the immunohistochemical staining for blood group substaces on the specimen. This application resulted in the prevention of unnecessary gastrectomy. The same demonstration was performed in another case. When the biopsy diagnosis is wholly different from the endoscopic findings, we should consider the possibility of various mistake. If the mishandling of the biopsy specimens were suspected, immunohistochemical staining for blood group substances could be very useful for the identification.

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A case of primary multiple malignant melanoma in the esophagus was reported. A patient was 68 year old man. Upper gastrointestinal fluoroscopic examination revealed two mass in the esophagus. By upper GI endoscopic examination, there also revealed two mass in the upper-midesophagus. One was pigmented blacky with a glistening surface. And another was not pigmented on gross. Both histological investigations of biopsy taken under endoscopic examination revealed malignant melanoma. Subtotal resection of esophagus was performed. On gross and microscopic findings of the resected specimen, there was two primary malignant melanoma with Junctional activity and melanocytosis.

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A 55-year-old female visited our hospital because of recurrent oral ulcers, pain in swallowing and paroxysmal dyspnea. She had genital ulcers 6 years ago and right sided gonitis 5 years ago. She has suffered from bronchial asthma for the past 3 years. She was diagnosed as having the incomplete type of Behcet's disease based on the history, laboratory data and physical findings. Barium enema revealed an ulcer and an ulcer scar in the terminal ileum. Upper GF series and endoscopic examination showed an elliptic ulcer in the middle esophagus. The esophageal lesions were observed endoscopically for 48 weeks. There were various forms of esophageal manifestations such as erosions, shallow or deep, small or large ulcers. They were elliptic, round, longitudinal or irregular in shape. All lesions were localized in the middle and lower esophagus. The cause of co-existence of Behcet's disease and bronchial asthma is not clear at present.

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A 48-year-old female complaining of upper abdominal discomfort was admitted to our hospital because of a lower esophageal polyp revealed by an upper GI series. Endoscopic examination showed a pedunculated polyp in the lower esophagus close to the esophagogastric junction, and endoscopic polypectomy was performed. The polyp had a smooth white surface with a partial erosion and was 16×16mm in diameter. Histologically, the polyp was an inflammatory fibroid polyp showing proliferation of small vessels and fibroblasts and marked infiltration of inflammatory cells which were predominantly eosinophils. The inflammatory fibroid polyp of the esophagus is very rare, and this paper is the first report in Japan. In addition, we reviewed 11 cases of the polyp reported in American and European literatures.

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Dieulafoy's ulcer is a relatively infrequent lesion as an etiological factor of gastric bleeding. Case reports of this lesion histologically proven are rarely encountered because of the recent development of non-surgical therapy such as urgent endoscopy and endoscopic hemostasis. Case report : A 59-year-old man with appetite loss and iron deficiency anemia due to multiple gastric ulcers of the middle body and an advanced gastric cancer of the antrum was referred to our clinic. As spurting bleeding from the posterior wall of the gastric middle body and an advanced gastric cancer were disclosed at endoscopy on the second hospital day, an endoscopic local ethanol injection therapy for hemostasis was attemted, resulting in failure and emergent surgical operation was performed. Histology of the surgical specimen showed a well differentiated tubular adenocarcinoma and multiple benign gastric ulcers, one of which was confirmed as a Dieulaf oy's ulcer.

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We reported a case of an extremely large common bile duct stone which was success-fully treated by electrohydraulic lithotripsy under peroral cholangioscopy. The patient was a 47-year old-woman who had complains of epigastric pain and vomiting. The common bile duct stone was diagnosed by abdominal ultrasonography and ERCP showed the presence of a large 60×26mm stone. Electrohydraulic lithotripsy was performed under peroral cholangioscopy. An equipment used included a mother-baby f iberscope (mother : TJF-M 20, baby : CHF-B 20, Olympus). A crushing device was the “Stone Disintegrator” (model SD-1, Northgate Research Co. USA.), and a 3 Fr single axle bi-polar electrode was utilized. After two sessions of lithotripsy, the stone was reduced to about 25×21mm in size, being accompanied by smaller fragments. A usual mechanical lithotriptor and a basket catheter were then used to complete the task. An analysis of the stone showed a composi-tion of 84% cholesterol and 16% bilirubin calcium. This case also involved an unfused pancreatic duct.

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A case of early pancreatic head carcinoma demonstrating intracanalicular growth in common bile duct was reported. A 63-year-old woman complaining of pain in epigastrium was admitted to our hospital for the further evaluation. DIC and CT revealed dilatation of common bile duct. US demonstrated isoechoic mass lesion without acoustic shadow around the terminal common bile duct. ERCP revealed a space occupying lesion with slight movement at the lower common bile duct accompanied by dilated common bile duct. Well def f erentiated adenocarcinoma was confirmed by the specimen of tissue from common bile duct. Pre-operative diagnosis of carcinoma of the common bile duct was made. Pancreatectomy was performed. Histology of the resected specimen demonstrated early pancreatic head carcinoma originating from the pancreatic duct with intracanalicular growth into the common bile duct. The wall of the common bile duct was intact.

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A 76-year-old man who lived in Kochi prefecture was admitted to our hospital with choledocholithiasis. He had fever, diarrhea, edema of legs and hypoproteinemia after choledocho-jejunostomy. Fecal examination showed the rhabditiform larvae of Strongyr-oides stercoralis. Fecal al-antitrypsin clearance in this patient was increased. Barium meal examination demonstrated edema, stenosis and superficial ulcerations from the ileum to the transverse colon. Soon after treatment with pyrvinium pamoate and thiabendazole, the larvae was not detected in his feces. The results of blood examinations and his symptoms were gradually improved. X-ray reexamination after treatment revealed improvement in the appearance of the small intestine and colon.

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A 19-year-old female was admitted to our hospital because of fever attacks, intermit-tent whitish stools and pretibial pitting edema. Laboratory examinations on admission demonstrated the following abnormal findings ; T. P. 3.4 g/dl, absolute lymphocyte count 377/mm³, and ¹²⁵I-PVP test 5.2%. Duodenal and jejunal endoscopic examinations showed scattered white spots and white villi, from which the biopsy specimens revealed dilated lymphatics in the mucosa. On lymphangiogram, marked tortuosity and irregular dilatation of para-aortic lymphatics were seen. Since underlying causes of lymphangiectasia were not evident, she was diagnosed as having primary intestinal lymphangiectasia, and was treated successfully with a defined formula diet containing medium chain triglyceride, namely, the presenting symptoms, laboratory data and endoscopic findings were markedly improved about 1.5 months after the treatment.

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A 65-year-old man was admitted for the treatment of the early gastric cancer. Before the gastrectomy, barium enema was performed as an routine examination for preoperation, which revealed a pedunculated polypoid lesion with smooth surface in the descending colon. On colonoscopic examination, the pedunculated polypoid lesion had reddish surface without ulceration, and colonoscopic polypectomy was performed unevent-fully. The resected specimen was 20×12×10 mm in size. Histologically the tumor had congestive colonic mucosa and was composed of spindle cells running in various direction that developed from the muscularis mucosa. Atypical cell or mitosis was not observed, so the tumor was considered as a colonic leiomyoma. It is suggested that the colonoscopic polypectomy is useful for the diagnostic method and treatment of a colonic leiomyoma, when its shape is pedunculated or semipedunculated.

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ERBD with use of a large caliber endoprosthesis (14 Fr.) was attempted in 8 patients ; 4 patients with pancreas cancer, 3 patiens with biliary tract cancer and 1 patient with chronic pancreatitis. The 14 French endoprosthesis has an external diameter of 4.6 mm and an internal diameter of 3.3 mm. A duodenoscope with instrument channel of 5.5 mm made by Olympus Optical Co. (TJF-M 20) was used in this study. The procedure was succesfully performed in 6 of 8 patiens without any complications, getting good drainage effects. With use of the 10 or 12 French endoprosthesis, it was necessary to clean or to replace the tube by follow-up endosdopic examination in every 3-4 months. Using a 14 French endoprosthesis, the procedure decreases the risk for occlusion of the tube and can release the patients from more limitation of the daily life.

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Abnormal arrangement of the pancreato-biliary ductal system (AAPB) is considered to be a high risk state of biliary carcinoma. To evaluate the diagnostic ability of endoscopic ultrasonography (EUS) for this condition, four cases of AAPB were examined with EUS and the results are presented in this paper. EUS could delineate the abnormal arrangement in all the four cases as endoscopic retrograde cholangio-pancreatography (ERCP) did. The classification of the arrangement by EUS well corresponded to that of ERCP. EUS will be performed more routinely with the advance of the instrument. The case diagnosed AAPB by EUS initially will be reported in the near future.

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