Thirty seven cases were studied to evaluate the ability of endoscopic ultrasonography (EUS) in diagnosing the depth of invasion in advanced gastric cancer with depressed lesion. We deviled into two groups, such as mass-formed type (32 cases) and mass -unformed type (5 cases). The results were as follows; 1) The depth of invasion was accurately estimated at 55 .6% in pm cancer, 50.0% in ss cancer, 83.3% in se cancer, 66.7% in sei cancer in mass-formed type by EUS . It was possible to estimate that the depth of invasion in mass-unformed type was ss or more invasion, but it was impossible to differentiate between ss and se invasion (Table 2). 2) Homogenous echoic pattern and abrupt obliteration of the third layer was fre quently shown in advanced cancer with depressed lesion by EUS, but fusion was hardly shown in it. Symmetric and clear border was often shown in Borrmann 2 type, asymmeric and unclear brader in Borrmann 3 type, symmetric and unclear border in IIc-like advanced cancer (Table 3). 3) Echo level was classified three types such as Table 4. Comparative high echo (Type 2 or 3) was shown in medullary type and comparative low echo (Type 1 or 2) in scirrhous type on the basis of relationship between cancer tissue and stroma. 4) We studied the correlation between growing pattern of the tumor and the depth of invasion. Inward growth was frequently shown in pm cancer but it was not shown in sei cancer. Outward growth was often shown in ss cancer or se cancer and it was show n in all of sei cancer. It suggested the growing pattern in advanced gastric cancer with depressed lesion strongly correlated with the depth of invasion (Table 5, 6).

View full abstract

Reddish patch and/or undulation of liver surface is the characteristics in peritoneoscopic findings of primary biliary cirrhosis (PBC). We studied about liver histology of the cases with PBC comparing with peritoneoscopic findings of them with special reference to the atypical findings of liver surface. The findings of reddish patch and/or undulation were observed in 52 (78.8%) among 66 cases of PBC in this study. The cases with some findings, such as various reddish marking, uneveness or miliary nodule, in addition to reddish patch and undulation, and the cases without both findings described above were defined as the cases with atypical peritoneoscopic findings. In the cases with diffuse reddish marking on the liver surface, piecemeal necrosis and sinusoidal cell infiltration were frequently observed. Furthermore, in the cases of CAHPBC mixed type, it was suggested that the liver surface of them with rough and large uneveness and diffuse hemorrhagic reddish marking reflect the histological changes of bridging necrosis and inflammatory cell infiltration peculiar to the PBC of this type. On the other hand, the incidense of chronic non-suppurative destructive cholangitis (CNSDC) was low in the cases with smooth liver in peritoneoscopy. These cases were regarded as the earliest stage of PBC. In the cases with miliary nodules on the liver surface, CNSDC and demarcated granuloma were frequently observed.

View full abstract

Sixty cases of depressed type of early gastric cancer and depressed type like advanced cancer were studied. The shape of converging fold was classified into four types under grade of deformity type A, B₁, B², and C in order of slight to severe degree. Fibrosis of the base of the ulcers were diagnosed with EUS. In each type of converging folds, the depth of invasion of gastric cancer was studied . As a result, in the same type of converging folds, the invasion of gastric cancers without fibrosis tended to be deeper than that of gastric cancers with fibrosis. The depths of invasion in cases with fibrosis were as follows: In A and B₁ type, depths of invasion of cancer and the spreads of fibrosis in B₁ type were deeper than those in A type. In B₂ type, many cases of B₂ type with ul-II, ul-III were of sm cancer, but many cases of B₂ type with ul-IV were of m cancer. As a result, the accuracy rate of the diagnosis of the depth invasion of gastric cancer has improved in 55% to 77%. As mentioned above, the diagnostic ability of the depth of invasion of gastric cancer with fibrosis was improved by using EUS findings in addition to endoscopic findings.

View full abstract

Total 30 endoscopic ultrasonography (EUS) were performed in 13 patients with ulcerative colitis (UC), using the specially designed echo -colonoscope system developed by Olympus Co. The normal colorectal wall was clearly visualized by EUS in five -layered structures as we have already reported. The ultrasonograms of UC in active stage showed hypoechoic changes of the colorectal wall, especially in the mucosal layer or in both mucosal and submucosal layers. These EUS changes of the wall recognized in a ctive UC usually disappeared or normalized in the stage of remission. When the state of UC exacerbated the hypoecholc changes of the wall seemed to be widened from the mucosal to submucosal layer with the increase of the wall thickness. These EUS images of UC were classified into three types ; type 1 showed no changes of the wall, type 2 demonstrated the hypoechoic changes of the 1st layer and the thickening of the 2nd layer, and type 3 manifested the hypoecholc changes with unclearness of boundary from the 1st to 3rd layer. The changes of EUS images of UC also corresponded with Matts' endoscopic grad es and the clinical severity of Truelove and Witts . In addition, we tried to make an EUS criteria for a better understanding of clinical severity of UC as an inflammatory volume ; we judged an affected location of the disease in horizontal direction with the aid of endoscopy in EUS and inspected the depth of inflammation in vertical direction by ultras onography in EUS. By introducing this new dimension, we were able to recognize the degree of inflammation in UC as the volume and it became possible to understand the cli nical severity of the disease more precisely. From these results, it is apparent that EUS is a valuable method in the diagnosis and therapy of UC.

View full abstract

A retrospective study was made of 25 patients treated for myogenic tumors of the stomach (18 cases of leiomyoma and 7 cases of leiomyosarcoma) in an attempt to evaluate the correlation between clinico-pathological findings and prognosis. We distinguished leiomyomas from leiomyosarcomas according to the number of mitosis, cellular atypia, and th e gross size of the tumor. All leiomyomas were smaller than 4 cm. In contrast, all leiomyosarcomas but one were larger than 5 cm. Mitotic figures in leiomyomas ranged from 0 to 3 per twenty high-power fields, while those in leiomyosarcomas ranged from 4 to 33. All patients with leiomyomas survived; all but one with leiomyosarcomas died as a result of the tumor within 4 years after operation. These criteria were judged to be adequate from a prognostic standpoint.

View full abstract

From January 1983 to October 1986, we observed 8 patients with gastric ulcer which showed mucosal protruding changes in ulcer floor at the healing process. The incidence is 1.8% . A ratio of male to female was 7 : 1. A mean of age was 64 years, ranged 49 to 75. Seven of the patients had hematemesis or melena. The most common site of the lesions was the angulus of the stomach. The size of the ulcers in 5 patients were above 2cm in diameter. Seven patients were treated with cimetidine and a patient with famotidine. Gastric ulcers with mucosal protruding changes tended to be large in size and old in age, compared with those in control group. Most of mucosal protruding lesions appeared in 4 to 7 weeks after the active stage of the ulcers. Histological examination of biopsy specimens obtained from protruding lesions showed the presence of granulation tissue. We classified the protruding lesions into 3 types according to their shapes. The days required to improve from the active stage to the scarring stage were longer in these 8 patients than in control group. It was suggested that these protruding lesions would develop due to unusual rapid repairment and over growth of granulation tissue of ulcer floor.

View full abstract

The endoscopic features of gastric adenomas were studied in 55 patients (69 lesions) whose diagnosis was confirmed by means of gastrectomy or polypectomy. Of the 55 gastric adenoma patients, the coexistence of gastric adenocarcinoma was observed in 13 cases (23.6%) and adenocarcinoma in adenoma (focal cancer) was seen in 9 cases (9 out of 69 lesions, 13.0%). To examine the endoscopic features of gastric adenomas, the cases were divided into the following three groups : cases of adenoma without coexistent adenocarcinoma, cases of adenoma with coexistent adenocarcinoma at a different site, and cases of focal cancer. No difference in location, shape, and color of the lesions could be demonstrated among the three groups. The larger the lesion size, the more frequent were the focal cancers, but focal cancers could be found in lesions smaller than 9 mm in size. It is therefore difficult to predict the existence of focal cancer only through endoscopical findings and' furthermore, the diagnosis of focal cancer cannot be made by endoscopic biopsy. It is considered that polypectomy or strip biopsy of the lesion is necessary for the definite diagnosis of adenoma. On the other hand, multiple adenomas were observed in 9 patients, of whom the coexistence of gastric adenocarcinoma was seen in 4 patients (44.4%) and focal cancer was observed in 3 patients (33.3%). As patients with multiple adenomas are assumed closely related to gastric adenocarcinoma, attention should be paid to their management.

View full abstract

A 72 year old male was referred to our hospital for an esophageal polyp. A barium swallow study showed about 1 cm polypoid lesion in the middle esophagus (Figure 1). Endoscopic examination revealed a pedunculated tumor about 33 cm from the incisors (Figure 2 and 3). The tumor surface was smooth and covered with whitish yellow esophageal mucosa and it felt soft by compression of biopsy forceps. Endoscopic polypectomy was successfully performed at the stalk of the polyp by a snare with electric coagulation. No bleeding was observed. The excised specimen was measured 6×5×4 mm. As a result of microscopic examination, it turned out to be a capillary hemangioma (Figure 3 and 4). This is a very rare tumor of the esophagus and only 44 cases including Blue rubber bleb nevus syndrome etc. have been reported in Japan. Endoscopic polypectomy was performed in 9 of those cases. According to analyses of those cases, endoscopic polypectomy could be done safely without bleeding, if the hemangioma is small and pedunculated. Also endoscopic polypectomy is the first choice of examination and treatment for a small and pedunculated polyp, if it is not a part of multiple tumor diseases.

View full abstract

A case of bleeding esophageal varices in the pregnant successfully treated with ndoscopic Infection Scierotherapy (EIS) was reported. A 37-year-old woman with alcoholism was admitted to our hospital complaining of massive hematem esis on December 23, 1988. On admission, she was in the 28th week of pregnancy. Emergency endoscopy revealed rapture of esophageal varices. EIS with 2% TSS (Tetradecyl sulfate of sodium) was performed safely and complete hemostasis was obtained. MRI showed the atrophic liver, splenomegaly, and the pregnant uterus compressing the inferior vena cava. Cesarean section was done in the 34th week of pregnancy because the pati ent was an elderly primipara. The newborn baby was completely healthy. The patient and her baby have been in good health up to now. In the Japanese literature, only 2 cases of bleeding esophageal varlces in pregnancy have been reported since 1970, and the patients and babies resulted in death in both cases. We conclude EIS is a safe and useful therapy for bleedingesophageal varlces even in the pregnant.

View full abstract

The patient is a 16-year-old girl diagnosed as having dwarfism and chronic mucocutaneous candidiasis three years prior to the present illness. Recently she had been treated for pneumonia, and liver dysfunction was found without symptoms of digestive system. Computed tomography performed for evaluation of the liver showed thickening of of the lower esophageal wall. Endoscopic examination showed the mucosal bridge connecting the anterior and posterior walls of the lower esophagus, with reddening and erosive mucosa. Sliding hernia and gastric ulcer in the lesser curvature of gastric cardia was found. Multiple biopsies of the lower esophageal mucosa under endoscopic guidance showed severe esophagitis without Candida. It was presumed that the mucosal bridge in this case was caused by reflux esophagitis. The second endoscopic examination showed persistent mucosal bridge after four months. Esophageal mucosal bridge is a very rare finding, and it is hypothesized that the mucosal bridge is formed in the healing processes of inflammatory lesions or ulcerations.

View full abstract

The case is a 58-year-old woman, who has become aware of edema since October 1985. UGI endoscopy in July 1986 confirmed giant rugae on the greater curvature of the body, and mucosal hypertrophy and multiple polyps ranging from the lower part of the body to the antrum. Histological picture of biopsy revealed crypto-epithelial hyperplasia, and interstitial edema, but the electron microscopic picture showed no abnomality. Serologically, decreases in T. P. (4.9 g/dl) and Alb. (2.3 g/dl) were noted. ¹³¹I-RISA test revealed protein leakage and increased gastric protein concentration (1.7 g/l compared with 0.26 g/l for healthy normal subjects). These findings led us make a diagnosis of Ménétrier's disease associated with hypoprote inemia on this patient. Combined therapy with cimetidine (800mg/day) and pirenzepine (100mg/day) give rise to significant increases in T. P. and Alb, and disapperance of the edema in 6 weeks. No change was noted in the endoscopic picture, histological picture and gastric protein concentration in the course of disease.

View full abstract

A 50-year-old woman with discomfort in the epigastrium visited our hospital and underwent gastrointestinal endoscopy. Soon after the examination the patient was noticed her unnatural attitude; i, e. she was confused as to time and place, and she asked repeatedly "What time is it?" to a doctor. There was no past history of epileptic seizure and cerebrovascular disorder. Neurological examinations revealed no abnormality other than deficit of short term memory. Namely she could correctly answer routine questions about her family and past history, but she could not recall the contents told to her a few minutes ago. She had completely forgotten the endoscopic examination as well as other happenings for 6 hours from the onset of examination. Long term memory was not disturbed. She was admitted. On next day's morning, her memory storing had completely recovered, but she could not recall what happened during the episode, MRI-CT of the brain, taken on the day of admission, showed no abnormality. An EEG, SPECT (Single Photon Emission Computed Tomography), and brain CT on the next day of admission were also nomal. The etiology of transient global amnesia is still unknown remains obscure, but most authors attribute transient global amnesia to a transient ischemic atack or epilepsy. Transient global amnesia may also be related to emotional, physical stress or painful stemulation. Examina tion of gastrointestinal endoscopy is stressfull for patients. Actually, after endoscopic examination aute gastric mucosal lesion may be induced. Although transient global amnesia is a rare hazard of gastrointestinal endoscopy, we should recognize it.

View full abstract

We experienced a case of traumatic intramural hematoma of the duodenum which was observed endoscopically. A 14 years old male was admitted to our hospital because of upper abdominal pain and vomiting. Five hours before the admission, he had a strong blow to his abdomen with the ground while playing soccer. The upper gastrointestinal radiography showed stenosis at the level of the second and third portion of the duodenum which was diagnosed as intramural hematoma of the duodenum. We had started the conservative management with intravenous hyperalimentation and observed the regression of the hematoma on CT scan, ultrasonography and endoscopy. Endoscopic examination revealed the elevated lesion with dark-reddish color in the duodenal lumen on admission. After the successive treatment, these findings subsequently disappeared accompanied with the improvement of clinical symptoms. Through the conservative management, the patient could have a peroral diet on 16th hospital day and discharged on 37th hospital day. Our case suggests that duodenal hematoma may be treated conservatively in case with no other associated injuries, and that, in addition to CT scan and ultrasonography, endoscopy is very useful not only for the diagnosis but also follow-up of the duodenal intramural hematoma.

View full abstract

A 55-year-old woman admitted to our hospital because of acute crisis of chronic myelocytic leukemia (Table 1). After admission, therapy with prednisolone 60mg/day, 6MP 100mg/day and vincristine lmg/week was begun (Figure 1), but abdominal pain and diarrhea was appeared after 47 hospital days, and multiple ulcers of colon were detected on barium enema examination (Figure 2) and on colonof iberscopy (Figure 3). Emergency operation was done after 62 hospital days since melena (5007, 000 ml/day) was occured and any therapy was uneffective. On operation, a numerous ulcers were found in the small and the large intestine (Figure 4). After operation, prednisolone was diminished gradually and discontinued, but the patient was died of suppurative peritonitis. At autopsy, ulcers of small intestine and colon were remarkably decreased in its numbers (Figure 6). Therefore, it is suggested that multiple ulcers of small intestine and colon of this case were induced by prednisolone from the histologic studies (Figure 5) and clinical course.

View full abstract

A 42-year-old woman was admitted to a local hospital on Februrary 26, 1985, with the sudden onset of watery diarrhea, hematochezia, abdominal pain and high grade fever. For three days before admission, she was prescribed AB-PC 2g by a practitioner because of lumbago. Sigmoidoscopy on that day of admission disclosed reddish edematous mucosa, and narrowed lumen of the sigmoid colon and descending colon, and normal mucosa in the rectum. Barium enema following the sigmoidoscopy showed thumb printing and narrowed lumen from descending colon to transverse colon. At that time, antibiotics-associated colitis was most likely. Later, the diagnosis of salmonella infection of the colon was made by cultures of a stool sample which was recognized colonies of salmonella typhimurium. Subjective symtoms completely disappeared 40 days after admission. Thus, when colitis occured during the treatment of antibiotics. salmonella infection of the colon should be considered in addition to antibiotics associated colitis.

View full abstract

A 37-year-old woman with an 18 year history of rheumatoid arthritis was admitted to our hospital with complaints of pain in the left lower abdomen, watery and bloody diarrhea, arthralgia, and fever. Laboratory data on admission were as follows; erythrocyte sedimentation rate (ESR) 139mm/hr, positive RA test RAHA titer 1:1280, antinuclear factor titer 1:160, and positive LE test. Barium enema studies showed a tubular narrowing in the rectosigmoid colon. Endoscopic findings showed red, edematous mucosa, circumferentially narrowed, with a tendencyy to easy bleeding in the same lesion. On inferior mesentric angiography, stenosis and occlusions were seen in the superior rectal and sigmoid arteries. Angiographic findings correlated with those from barium enema and endoscopic studies. She suffered congestive heart failure due to myocarditis during the course, and was diagnosed as having malignant rheumatoid arthritis.She died of peritonitis caused by perforation in the jejunum one year after the onset of intestinal infarction. Pathologically, small and medium sized vessels of the resected mesenterium showed EA type vasculitis under Kyogoku's vasculitis classification. There have been very few reported cases of malignant rheumatoid arthritis with intestinal infarction and perforation in the jejunum.

View full abstract

A 35-year-old man was admitted to our hospital with complaints of polyarthralgia and diarrhea. The patient had been treated with sulfasalazine since 1985 because of the diagnosis of ulcerative colitis. The patient had a complaint of epigastralgia in 1986 and endoscopic examination showed an active duodenal ulcer. The patient had been treated with sulfasalazine, cimetidine and sucralfate. One year after the episode, the patient had severe epigastralgia. Endoscopic examination showed active ulcer in the duodenal bulb, and a fistula between the gastric antrum and the duodenal bulb, which was so-called double pylorus. Although the ulcer was healed by drug therapy, double pylorus was extant. The acquired double pylorus was caused by penetration of the duodenal ulcer to the prepylorus as a result of psychological stress in patient with chronic ulcerative colitis and/or long term sulfasalazine therapy might be considered to be pathogenic factors of duodenal ulcer and its penertation to the antrum.

View full abstract

A 59 year-old male patient visited our hospital with a chief complaint of diarrhea. The barium enema showed a small filling defect in the terminal ileum ; The colonoscopic examination revealed a protruding lesion. The size of it was about 6 mm in diameter, and it located at 3 cm orally from the ileocaecal valve. Histopathological diagnosis of the biopsied specimen was tubular adenoma. Several trials of colonoscopic polypectomy failed and the adenoma was removed by surgical operation. A rare case of adenoma of the ileum is reported herein with a brief review of the adenoma of the small intestine.

View full abstract

Two cases of mucin producing pancreatic tumors, followed for four years, were experienced. The first case was a 68-year old female and was initially diagnosed as having the chronic pancreatitis with local dilatation of the main pancreatic duct in the tail of the pancreas. ERP done 4 years later demonstrated marked diffuse dilatation of the main pancreatic duct and findings of papilla of Vater showed characteristically the mucin producing pancreatic tumors. Surgical management was performed and the tumor was histopathologically papillary adenoma. The second case was a 87-year old female with cystic lesion in the body of the pancreas. Findings demonstrated by CT and pancreatogram by ERP showed no marked interval change after 4 years. The tumor was histopathologically the intraductal papillary adenocarcinoma. Findings of the pancreatic duct and papilla of Vater seemed to be mainly affected by the amount of mucin from the tumor. There was no relation of degrees of histopathological malignancy. Local dilatation of the main pancreatic duct supposed to be an inital change of the mucin producing pancreatic tumor in association with a development of diffuse dilatation of the main pancreatic duct.

View full abstract

Eighty three patients (107 cases) undergoing ERCP, endoscopic sphincterotomy (EST), endoscopic variceal sclerotherapy (sclerotherapy) and colonoscopy were intravenously administered f lunitrazepam as the preendoscopic medication agent. The drug was diluted in lOml saline and injected intravenously in volume of 0.025 mg/kg. Sedative effects were shown in all cases and in the state of closing eyes verbal responce was observed 96 cases (90%). Amnesic effects were identified in 28 of 30 cases (93%). The mean recovery time was 186 minutes. Depression of systolic blood pressure, greater than 40% compared to the premedicative pressure were obvserved in 5 cases (4.6%). Transient excitement and eupholia were noted in 4 cases (3.7%). The pain durindg endoscopic examination was remembered in 7 cases (6.5%). The only one patient complained of arm pain. Flunitrazepam is a very useful intravenous sedative agent for endoscopy in addition to its strong amnesic action.

View full abstract

Endoscopic polypectomy using high frequent electric current is recently prevalent as a treatment of colorectal polyps and cancers. However, it is technically difficult for the treatment of flat or broad-based polyps. We have already reported that the heat probe method which was developed as the endoscopic hemostatic method, was useful for the treatment of colorectal lesions which were difficult to remove by the conventional endoscopic polypectomy. Heating probe of this equipment was reformed and the tip of the probe was made larger, 4.5 mm in size, to burn out the broad-based tumors at one time. By these improvement, colorectal polyps were easily burnt out by an application of electric current and treated by little heat. Therefore, this procedure became more safely.

View full abstract