The aim of this study was to define the difference of pathophysiology between complicated reflux esophagitis, such as, Barrett's epithelium and esophageal stricture (13 cases) and uncomplicated reflux esophagitis (7 cases). Moreover, we try to set up rational approach for complicated reflux esophagitis by esophageal manometric study, and 24-hour intraesophageal pH monitoring. The gastroesophageal reflux was defined as a fall in intraesophageal pH below 4.0, and semiquantitation of regurgitated acid was obtained by weighing the area of the ref lux. Obtained result showed no significant difference of LESP between complicatied and uncomplicated cases (p>0.10). However, semi-quantitated acid regurgitation showed that complicated cases had significantly increased acid regurgitation than that of uncomplicated cases indicating 24 -hour pH monitoring (p<0.01) reflected the pathophysiology of reflux esophgitis better than measuring LESP. Furthermore, the 24-hour pH monitoring was useful to define the adequate dosage of the Cimetidine to control acid reflux in patient with complicated reflux esophagitis. With such adequate dosage of H2-blocker, we could obtained excellent therapeutic effects including symptomatic relief, healing of ulcer and resolving or regression of Barrett's epithelium in almost all the patients.

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We observed gastric erosions with an electronic endoscope (TV-Endoscope) and divided the healing process into five stages (A, H, R1, R2 and R3), according to the presence or absence of black or white base, edema and reddening (Table 1). In addition, we studied the frequency at each stage of the erosions both on the fundic and pyloric gland mucosa (Table 2). The difference between these frequencies on two types of gastric mucosa was statistically significant at <0.01 level. The erosions at healing (H) stage on the pyloric gland mucosa showed higher frequency than that at active (A) stage, but on the fundic gland mucosa the frequency at A stage was higher than that at H stage. On the other hand, at R1 and R2 stages the frequencies were similar on both gland mucosa. The frequencies at R3 stage were 35% and 5% on the fundic and pyloric gland mucosa, respectively, and there was a significant difference between them. The erosions at this stage on the fundic gland mucosa usually showed depression and were, therefore, easily detected. We also studied the minute structure such as gastric pit and sulculus, on the surface of gastric erosions at each stage, and found that they were divided into two patterns. The one resembled the surface structure of the surrounding normal mucosa, the other was spindle-like or palisade-like pattern similar to that found during the healing process of gastric ulcer. It appears that the former corresponds to the shallow erosion and the latter is the deeper erosion of which the mucosal defect reaches the muscularis mucosa and the regenerative mucosa arises from the surrounding mucosa and extends to the center of the erosion like gastric ulcer. The frequencies of the erosions with the spindle-like or palisade -like regenerated epithelium were 10 to 25% at H and R1 stages on the fundic and pyloric gland mucosa.

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A follow-up study of 36 Campylobacter pylori (CP) infected patients and 6 non-infected patients of the gastro-duodenal diseases were carried out in order to clarify the natural course of CP infection. In all 42 patients, 30 were males and 12 were females. The mean age was 52 years old (19-78 yo). The mean follow-up period was 148 days (7-469 days) and mean examination frequency was 2.5 (2-5) times. In all 42 patients, 17 were gastric ulcer, 8 were duodenal ulcer, 3 were gastro-duodenal ulcer, 9 were gastritis, 4 were gastric cancer, and 1 was gastric polyp. All patients did not receive antibacterial treatment during this follow-up period. CP was detected by culture, urease test and acridine orange stain. In 36 CP infected patients, 32 showed persistent infection and 4 showed spontaneous resolution of infection. In 6 CP non-infected patients, 4 remained CP negative and 2 became CP positive during the follow-up period. CP detection rate was 100% in gastric ulcer (A1-H2 stage), 90% in gastric ulcer(S1-S2 stage), 100% in duodenal ulcer (A1-S2 stage), 56% in chronic gastritis and 63% in gastric cancer. In conclusion, 1) most CP infected patients showed persistent infection, 2) spontaneous resolution of CP infection was rarely seen, and 3) the greater part of peptic ulcer patients remained CP positive even in the scar stage.

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Twenty-two patients with Crohn's disease who were operated at our hospital and followed-up for more than 5 years were clinicopathologically studied. Involved portion of intestinal tract were 10 in small bowel, 12 in small and large bowel and one in colon. Major indication for surgery are as follow ; stenosis, fistula formation, perforation peritonitis and intractability of medical treatment. In 17 cases, the lesions were resected completely, but recurrence was found in 7 cases (small bowel type 5, small and large bowel type 2). Mean intervals of recurrence in small bowel cases were 8 months. Initial recurrences were found at the suture line, and did not show wide spreading in subsequent periods. Two patients were required the excision of the recurrent lesions because of remarkable stenosis 5 years 6 months and 9 years 8 months after surgery, respectively. Five cases of small and large bowel types were remained lesions of resected intestinal margin at the time of resection. The remained suture line lesions were unchanged for a long period. Multiple aphthoid ulcers and small ulcers disappeared by medical treatment. Three of these were almost good condition as for the quality of life after surgery. However, two cases residued skip lesions of sigmoid colon were not so good condition because of intractability of medical treatment. Medical treatment for recurrence or surgically remained lesions of Crohn's disease were effective.

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Endoscopic ultrasonography was performed in 56 patients with colorectal cancer to evaluate the invasion and lymph node metastasis. The instruments employed were echo-colonoscopes, XCF-UM1 and XCF-UM2 (Olympus). A scope could be inserted into the site of lesion in all cases. Ultrasonographic visualization of the lesion was, however, possible in 40 cases (71.4%). Visualization was possible in all cases of rectal cancer ; the rate of visualization tended to be lower when the lesion was located in other sites. The proportion of the lesion to the total circumference and the degree of narrowing tended to inversely correlate with the rate of visualization. The rate was higher in cases with early cancer compared to those with advanced disease ; in the latter patients, the rate tended to be higher when the lesion was protruded. The extent of invasion was correctly evaluated in 36 (90%) out of 40 cases in which visualization was possible. When ultrasonographic visualization was possible, the rate of correct diagnosis of invasion was unrelated to the site of lesion, the proportion of the lesion to the total circumference, the degree of narrowing, or the extent of invasion. Metastasis to the lymph nodes beneath the wall could be detected in 7 (41.2%) out of 17 cases in which lymph node metastasis was proved. Reactive lymph node swelling was observed in 2 cases ; ultrasonographic differentiation was impossible between metastatic and reactively swollen lymph nodes. Endoscopic ultrasonography can yield important information for the recognition of cancer extention. The usefuleness of the examination is, however, limited when the narrowing in remarkable. The development of echocolonoscope with smaller caliber is desired.

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Although the technique for imaging tissue hemoglobin distribution by analyzing electronic endoscopic images using two narrow-band interference filters of 569nm and 650nm, based on organ reflectance spectrophotometry, has some drawbacks such as the effect of regular catoptric lighting and insufficient light intensity, it does offer many useful advantages not available with conventional endoscopy. These advantages are as follows : 1. The ability to produce two-dimensional hemoglobin distribution charts. 2. The average hemoglobin concentration (hemoglobin index, Hb-I) can be measured within any region of interest (ROI). 3. Measurement can be performed under physiological conditions because a non-contact method is introduced in this system. 4. Errors in reproduciibility caused by changes in the examination method are avoided. 5. Instantaneous and repeated measurements are possible. Because of these advan-tages, this imaging method is highly evaluated for its great potential role in research and clinical applications.

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We performed injection scierotherapy using the tissue adhesive "Histoacryl(R) blue" (n-buthyl-2-cyanoacrylate) for refractory bleeding from gastric varices . Fundamental evaluation of the procedure prior to the clinical application indicated that Histoacryl(R) blue can be injected most safely with the minimum possibility of transport of the polymer to other organs as an embolizing material (embolus) when it is injected alone slowly over few seconds. We performed this treatment in two patients with bleeding gastric varices in whom hemostasis was difficult by conventional procedures and achieved complete hemostasis and dissapearance of the varices by the initial application of the therapy. No complications were observed due to the treatment. However, the use of Histoacryl(R) blue, which is not a genuine sclerosing agent, should be limited presently to bleeding from gastric varices (especially fundic varices) resistant to conventional sclerotherapy primarily using Aethoxysklerol. Further studies are needed to clarify indications of this therapy.

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Pathological investigation was done in 36 cases of colorectal cancer with invasion to proper muscle layer (pm cancer) and 64 cases of early colorectal cancer to know the developmental process of colorectal cancer. Pm cancers were macroscopically classified into three types according to the rules of colorectal cancer and gastric cancer, namely, type I, type II, and IIa+IIc like pm cancer. Microscopically, pm cancers were classified into four grade by vertical invasion in the proper muscle layer. It became apparent that vertical invasion of type I and ha +IIc like pm cancers were mild (grade lor2), and their sizes were almost less than 3 cm in diameter. In contrast, type II pm cancer tended to invade deeply (3 or 4) and their sizes were more than 4 cm in 17 of 23 cases. Although advanced colorectal cancer with subserosal invasion appeared grossly type II in most cases, 28% of pm cancers showed type I in gross appearance. Particularly, in the sigmoid colon, type I/type II ratio of pm cancer was 1 which was significantly higher than that of rectum (0.3). Survey of early cancers in the present study revealed that a group of tall early cancers consisted of Ip, Isp, and Is was predominantly in the sigmoid colon. Therefore, it was suggested that in the sigmoid colon, a group of tall early cancers grew slowly and developed into type II pm by way of type I pm cancer. Ratio of cancers associated with adenoma was 74% in mucosal cancer, 33% in submucosal cancers and 0% in pm cancer. Therefore, it was suggested that early colorectal cancer lost a component of adenoma in the process of developing into pm cancer.

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The picture of the stomach obtained by TV-endoscope system (Toshiba-Machida) was processed by means of histogram flattening of saturation in HSV color space, for the purpose of the improvement of detectability of small, flat lesions with minute changes in color. With the present method of image processing, subtle changes in color were distinctly enhanced, namely, the pale area becoming more pale and the red more red. As a fundamental study, the RGB elements were converted into HSV color space, being separated into hue, value and saturation elements, respectively. Then, the histogram of each separated element was analized. Consequently, only the histogram of saturation showed two peaks. From these evidences, it should be assumed that the changes in color of the gastric mucosa are ascribed to the difference of saturation. Pictures of a lesion of adenoma and two of early gastric cancer were processed through the histogram flattening in HSV color space. Each processed image of the lesion showed the strongly intensified color contrast to the surrounding normal mucosa. From these studies, it is concluded that an image processing of the histogram flatten-ing of saturation in HSV color spece will make it easier to detect flat and small gastric lesions with minute color changes.

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A case of carcinoma in remnant stomach as the complication of stomal polypoid hypertrophic gastritis (gastritis cystica polyposa) was reported. The patient was 54-year-old male to whom subtotal gastrectomy was carried out under a diagnosis of IIc III+ like advanced gastric carcinoma 19 years ago. He was admitted to our hospital because of further evaluation of green caterpilar-like protruded lesion in the remnant stomach. Similar finding was observed in the greater curvature proximal to the stoma by x-ray and endoscopic examinations. The mucosa with partial redness and erosion in the protruded lesion was gradually shifted to the normal mucosa. Biopsy from the erosion revealed group V. Partial resection of remnant stomach was performed under a diagnosis of remnant gastric carcinoma. Histology of resected speci-men was as follows; 1) Moderately differentiated adenocarcinoma limited to the invasion into the mucosa in the surface of the protruded lesion. 2) Below this layer, there are slight elongation of gastric areola, proliferation of pseudoantral glands with cystic formation, and slight degree of chronic cell infiltration indicating stomal polypoid hypertrophic gastritis. In addition, twenty-two cases of stomal polypoid hypertrophic gastritis including 11 cases which complicated carcinoma reported in Japan were briefly reviewed.

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A case of early gastric cancer resembling submucosal tumor was presented and the literature was reviewed. The patient was a 63-year-old female with a chief complaint of epigastric discomfort. Radiografic and endoscopic examinations of the stomach revealed a lesion suggestive of submucosal tumor with central ulceration. After the diagnosis of gastric cancer was confirmed by biopsy, subtotal gastrectomy was performed. Histopath-ological studies revealed localized cancer nests in the ulcerated portion assosiated with submucosal heterotopic gastric glands and marked proliferation of Collagenous fibers in the submucosa. The final histological diagnosis was moderately differentiated adenocar-cinoma with submucosal invasion (Sm). Reports on early gastric cancer presenting as submucosal tumor have been rare. In this case the protrusion was composed of cancer, submucosal heterotopic gastric glands, and the fibrous reaction in the submucosal layer. Collagenous fibers in the submucosa appeared to be the principal component of the protrusion.

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A 21-year-old female with a chief complaint of epigastric pain was referred to our hospital. A barium meal study revealed multiple ulcers at the gastric angle and antrum. An endoscopic examination demonstrated a variety of findings such as ulcers with white coating, erosions and hemorrhage at the same regions. With these findings, malignant lymphoma was intially suspected. But histologic examination on biopsy specimens did not reveal any findings suggestive of lymphoma or other malignant neoplasms. On laboratory examinations, the serological test for syphilis showed to be gastric syphilis. The abnormal endoscopic findings and titers of serological test for syphilis were remarkably improved 3 months after treament with Ampicillin. Finally, the diagnosis was confirmed by demonstra-tion of Treponema pallidum on biopsy specimens by silver staining technique using Wartin -Starry's method.

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Endoscopic ultrasonography (EUS) was done in a patient operated for Dieulafoy's ulcer due to A-Vmalformation (Figure 4). Low echoic shadow (Figure 6, 7) such as cylinder, bead and string like pattern (Figure 8) were seen in submucosa. As compared with resected specimen, low echoic shadows suggested the A-Vmalformation. Such findings of EUS have not been reported on the literatures as far as we knew. However, in reviewing the literatures on Diuelafoy's ulcer we presumed that a large vessel in the submucosa could be demonstrated in 41 of 64 histologically illustrated cases (64%) with EUS. The access of endoscopic hemostasis to the treatment of Dieulaf oy's ulcer has presented less specimens to investigate. EUS is useful for such conservative cases to estimate a large vessel of Dieulaf oy's ulcer.

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We reported a patient, 66-year-old female, with Ménétrier's disease whose gastric huge rugae were examined by endoscopic ultrasonography and whose protein-losing pattern from the stomach was studied by serial abdominal imaging with In-111 transferrin. This patient was admitted to Toyama Rousai Hospital because of edema and anemia. Abnormal laboratory findings were obtained as follows ; red cell count 3.75×10⁶/ml, hemoglobin 5.6 g/dl, serum iron 15 μg/dl and serum protein 5.3 g/dl, indicating remarkable iron deficiency-anemia and hypoproteinemia. Huge convoluted gastric rugae were found at the greater curvature of the stomach on X-ray and endoscopic examinations. Histology of gastric biopsy revealed glandular hypertrophic gastritis. Endoscopic ultrasonography demonstrated that huge gastric rugae consisted of hypertrophy of the mucous layer. Serial abdominal imaging with In-111 transferrin demonstrated protein-losing from the stomach. Under a diagnosis of Ménétrier's disease, she was treated with iron and famotidine, and then the levels of hemoglobin and serum protein have become normalized. She is still under this medical therapy.

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A 60-year-old woman was admitted to our hospital because of right hypochondralgia. Laboratory data showed liver dysfunction with a high level (3600 ng/ml) of alphafetoprotein. Various imaging studies revealed a tumor in the right posterior segment of the liver and a metastasis to the lymphnode in hepatoduodenal ligament compressing the common bile duct. In spite of the chemotherapy, the size of metastatic tumor was increasing. Epigastralgia and jaundice appeared suddenly, and various imaging studies revealed hemobilia and obstruction of the common bile duct due to clots. Endoscopic nasobiliary dranage (ENBD) and urokinase infusion were performed immediately, which was very successful for improving the symptoms. However five months after admission she died of hepatic failure. and the autopsy revealed hepatocellular carcinoma associated with cirrhosis, and the metastatic tumor of 9 cm in size was also found in the hepatic hilus invasing into the common bile duct. ENBD was thought to be a useful therapeutic tool for hemobilia caused by carcinoma.

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A 43-year-old female was admitted to our hospital because of hematemesis and tarry stool. She sometimes had complained of nausea and vomiting for 4 years before the admission. She was moderately anemic and CRP, fecal occult blood and PPD were positive. A chest X-ray picture was noncontributory. Hypotonic duodenography disclosed an irregular shaped ulcer and a stricture of the third portion of the duodenum. Similarly, duodenoscopy showed an irregular and shallow ulcer with a marked stenosis. The histopathology of the biopsy specimen revealed a caseating epithelioid granuloma containing Langhans' giant cells. Tubercle bacilli were recognized in the cultured biopsy specimen from the ulcer bed. The patient was diagnosed to have tuberculosis of the duodenum and antituberculous chemotherapy was then started. The patient condition was stable for 45 days and she again complained of severe vomiting after meals. A repeated hypotonic duodenography demonstrated that the ulcer healed but the stricture worsened. By-pass operation (gastrectomy and gastrojejunostomy) was performed. Thereafter, the patient was continued to have antituberculous chemotherapy for 1 year. The postoperative course was uneventful.

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A 68-yaer-old female case of intrahepatic cholangiocarcinoma with severe atrophy of the left hepatic lobe is reported. Computed tomography showed a low density mass in the medial segment of the left lobe and atrophy of the lateral segment. Laparoscopic observations demonstrated the atrophic, white and thin lateral segment, indicating loss of hepatic parenchymal cell mass. Cystic dilatation with waxy-white appearance was seen on the surface of the atrophic left lobe. Yellowish-white metastatic nodules were observed on the parietal peritoneum and forceps biopsy was done for histological examination. Histology of biopsy specimen from a metastatic nodule showed metastatic adenocarcinoma with dense fibrous stroma and bile duct-like acinous formation, suggesting peritoneal metas-tasis of cholangiocarcinoma. We concluded that the severe atrophy of the lateral segment resulted from an occlusion of the left hepatic bile duct branch by tumor cell invasion. Laparoscopy was useful for diagnosis of cholangiocarcinoma with the severe atrophy of the left lobe and showed a characteristic feature of the surface of the liver with cholangiocar-cinoma before clinical manifestation of jaudice.

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Floating gallbladder of Gross type B causes peritonitis by torsion more frequently than type A because of lacking the mesentery between the gallbladder and the liver. To estimate the prognosis of floating gallbladder needs to differentiate the two types. We investigated the usefulness of laparoscopy to differentiate the two types of floating gallbladder, Gross type A and B, by comparing with other examinations. Ultrasonography showed mobility of the gallbladder with changes of the patients positions but failed to distinguish the difference of the two types of floating gallbladders. Neither CT scan, nor cholecystography exhibited any abnormal position of the gallbladder. However, laporo-scopy could show the mesentery between the gallbladder and the liver, and provide the diagnosis of Gross type A or B.

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A 59-year-old man, who had been complaining of epigastric discomfort since 1985 and was pointed out the abnormal findings of the gall bladder by ultrasonography (US), was admitted to our hospital for further examination of the gall bladder on June 22 1987. No abnormal findings were detected on the initial laboratory investigations. US and CT showed an oval-shaped mass with a clear margin in the gall bladder. The main pancreatic duct and the cystic duct was detected at the same time on ERCP and an oval radiolucent mass with a clear margin was detected in the gall bladder. But the relationship between the common bile duct and the cystic duct was ulclear. Percutaneous transhepatic cholecys-tography revealed a movable well-defined oval-shaped mass in the gall bladder. Contrast medium flowed into the duodenum, but the common bile duct was not detected. The bile aspirated from gall bladder was a water-like non-colored liquid. This case was diagnosed cholecystolithiasis and cholecytectomy was performed. Intra-operative cholecystography showed the direct connection of the cystic duct to the main pancreatic duct and no detection of the common bile duct. There was a milky-white soft mass with a size of 60×40×25mm in the gall bladder. That was consisted of protein more than 99%. On the histological examination, mild inflammation without cancerous invasion was found. Postoperative ERCP showed that cystic duct connected the main pancreatic duct directly at the nearer part to the great duodenal papilla than at the bifurcation of Santorinii duct and there was no communication between the cystic duct and the common bile duct.

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The septum formation of the common bile duct was found in a 66-year-old female with choledocholithiasis. The patient was admitted to our hospital because of pain in the right hypochondrial region. Ultrasonogram showed a dilatation of the common bile duct (Figure 1). ERCP revealed a stone in the dilated common bile duct and a linear horizontal defect at its lower position (Figure 3). Postoperative choledochoscopy through T-tube showed a septum in the lower common bile duct (Figure 4). Histological evaluation on the septum by endoscopic biopsy revealed almost normal bile duct structure (Figure 5). The septum formation of the bile duct is a rare anomaly. Only 29 cases including the present case have been reported in the Japanese literature and were reviewed.

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A 82-year-old female was admitted to our hospital with hematochezia. A flat protrusion with redness was observed in the ascending colon by colonoscopy. Spurting bleeding occurred from this lesion after biopsy, and vascular disease was suggested. Selective angiography revealed as follows; 1) dilatation of the feeding arteries, 2) proliferation, tortuousness and aggregation of capillaries and 3) early venous return. Therefore, Vascular ectasia of the ascending colon was diagnosed. Twenty-six cases of Vascular ectasia of the colon have been reported in Japan. In most of these cases, the lesions were located in the right colon, which is different from adenoma. Therefore, it is suggested that a flat protrusion associated with moderate hemorrhage seen in the right colon could be Vascular ectasia.

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Intussusception in adult is known as a rare condition, and to the best of our knowledge, there are only 12 case reports in Japanese literature that adult Intussusception was observed by endoscope preoperatively. A 75-year-old male visited the clinic of our hospital with melena of four week'sduration. Rectal examination revealed a soft mass. Colonoscopic examination disclosed a large smooth surfaced tumor, which simulated a submucosal tumor, and an irregular polypoid lesion at the base of the tumor. The diagnosis of this polypoid lesion by means of endoscopic biopsy was adenocarcinoma. A barium enema carried out after admission disclosed that the smooth surface mucosa of the large tumor was related to Intussusception of the colon. Operation was performed. The polypoid lesion was 32×28×9 mm in size and pathologically diagnosed as well differentiated adenocarcinoma in which the depth of cancerous invasion was pm. It is a generally accepted opinion that intussusception in adult usually occurs secondarily to pre-existing neoplasms, and that most of the cases had a protracted clinical course prior to operation. Therefore, colonoscopy should be performed actively to make a correct preoperative diagnosis of the causative lesion.

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A 38-year-old male visited our clinic because of his abdominal pain and dirrhea. Clinical examination revealed leukocytosis. Because of his history of having Shimesaba (vinegared mackeral) in the previous evening, anisakiasis of the stomach was suspected. However, upper G-I endoscopy revealed no remarkable lesions. Colonoscopy showed a reddish edematous lesion in the transverse colon. In the center of the lesion, a worm was observed to thrust into the colonic wall. It was removed by using a biopsy forceps. After the procedure the symptom disappeared rapidly.

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A 52-year-old male patient has been followed under the diagnosis of Peutz-Jeghers syndrome since 1961. He began to have abdominal pain, abdominal fullness, and constipation in January 1987. Sigmoidscopic examination disclosed a polypoid mass which irregulary constricted the lumen of the sigmoid colon. Insertion of sigmoidscope beyond the lesion was unsuccessful. Biopsy specimens obtained from the polyps revealed to well differenciated adenocarcinoma. Operation was performed on September 10, 1987. Macroscopically, the cancerous lesion was 4cm in length. To date, twenty-eight cases of Peutz-Jeghers syndrome who developed colon cancer have been reported in Japan. But there was no report on such long term follow-up case.

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