In 27 patients with esophageal varices blood flow in the varices was investigated by color Doppler echography, before and/or after endoscopic injection sclerotherapy (EIS). In all patients, color display indicating blood flow by this method could be observed before EIS. Maximam blood flow velocity was able to mesure in 15 patients and its mean velocity was 11.8±6.4 cm/s. (mean+ S.D.) After EIS, 18 patients were investigated. Endoscopically, the forms of varices were improved to Fo in 2 patients and to F1 in 16 patients. In color Doppler echography color display disappeared after EIS in 14 out of 18 patients in whom the forms of varices changed to Fo in 2 patients and F1 in 12 patients. On the other hand, 4 patients whose varices became F1 after EIS showed still color flow indicating blood flow. These patients should be followed up strictly by endoscopic observation, because the recurrence of the varices was observed. In conclusion, intracavitary color Doppler echography was thought to be useful for the evaluation of the therapeutic effect by EIS.

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We evaluated the hemostatic effects of the heater probe and ethanol injection. The successful hemostasis by the heater probe was obtained in 94.4%, and by ethanol injection in 86.5% respectively. There were no significant difference between both hemostatic procedures. The disappearing incidence of the visible vessel by the heater probe (67.4%) was better than by ethanol injection (48.6%) (p <0.05). Rebleeding rates in two groups were not significantly different. There were no major complications such as enlargement of ulcer and perforation by the heater probe hemostasis. The effects of heater probe hemostasis was evaluated experimentally for the extent of injury of the gastric mucosa in dogs. The depth and width of injury were directly proportional to the energy applied by the heater probe. When 60 joules was applied, the injury extended to the submucosal layer. The area of degeneration was about 6mm in diameter. The hemostatic mechanism of the heater f robe was as follows; 1) constriction of the vessels. 2) degeneration of the smooth muscle and the endothelial cells of the vessels, and 3) the thrombus formation in the vessels. We conclude that the endoscopic heater probe hemostasis is a useful and safe method for acute gastro-intestinal bleeding.

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ERCP findings in 221 cases of carcinoma of the pancreas were divided into 5 types such as type 1 (Stenotic type), type 2 (Tapering type), type 3 (Obstructed type), type 4 (Dilated type) and type 5 (Unclassified type). The relationship between the type and survival, and the types and histological findings were investigated in this paper. The cases with type 4 showed the longest survival, the next longest survival was seen in type 3, and the shortest in cases with type 2. These differences were more significant in cases with carcinoma located in the head of the pancreas. In operated cases, Type 4 showed the smallest in tumor size and few carcinomatous invasion to the extra pancreatic resion. Therefore, resectability was highest in type 4. On the other hand, type 2 showed spreaded carcinomatous invasion in most cases and no cases were resected. Resectability were nearly the same in type 1 and type 3. Liver metastasis was seen in 45% in total and the rate in each type was inversely correlated with its survival. Histology in type 1 showed mostly tubular adenocarcinoma ; protuberant type on gross appearance, infiltrative type on cross section, intermediate-Scirrhous type on stroma and INF β-γ on extension. In contrast, type 3 showed mostly protuberant type, nodular type, intermediate-medullary type and INF β-α. Type 4 showed different histology from other types, such as papillary adenocarcinoma, nodular type, medullary type and INF α. In conclusion, the difference in survival in each type was thought to depend mainly on the histological difference.

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Electronic endoscopy provides clear and high-guality images and its usefulness for fine observation of duodenal villi is expected. We applied electronic endoscopy in combination with 0.2% indigo-carmine dye contrast method to 66 cases, and obtained clear observation of duodenal mucosal patterns (isolated, connected and atrophic) and granularly regenerated villi. In our study, granularly regenerated villi were observed in 33.3% of active duodenal ulcers, 100% of healing ulcers, 63.6% of red scars and 12.5% of white scars respectively. Therefore, granularly regenerated villi are one of the characteristic findings of healing process in duodenal ulcers, and important for the differential diagnosis between red and white scars. As for the background of duodenal mucosa in active duodenal ulcers, the connected pattern was dominant.

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Our long-term observation of prognosis in 186 patients with esophageal varices after endoscopic injection sclerotherapy (EIS) showed that an active treatment for remaining or growing gastric varices are necessary to improve the prognosis of thses patients. In the present study, we tried EIS by a direct injection method for gastric varices in 11 cases ; in 2 of 11 cases with bleeding varices as a emergency treatment and in 9 cases with risky gastric varices as a prophylactic treatment. EIS was performed under X-ray monitoring using contrast medium. In one case with projectile bleeding, complete hemostasis was obtained by EIS. However, EIS was unsucessful in another case whose bleeding point could not be confirmed. When the effect of EIS was estimated four weeks later, all varices were flattened or disappeared. Thereafter, no bleeding or no new growing of varices was observed during the observation period of 20 months maximally. Bleeding from the injection site was negligible by new technique of pulling out the needle. There was no serious complication by EIS. These results suggest that our EIS by a direct injection method under X-ray monitoring is a safe and effective therapy for gastric varices.

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Recently, we experienced a case of PSC and a case of common bile duct cancer in which the differential diagnosis could not be made by US, CT, FRCP, angiography, liver biopsy and EUS. In the PSC case followed-up for 2 years and 2 months, the common bile duct wall was visualized only as hyperechoic layer by US, although a thikened 3 layer structure composed of hyperechoic, hypoechoic and hyperechoic layers on EUS was seen. Moreover, EUS detected the thickened distal common bile duct wall, despite no remarkable findings of ERCP. In the case of common bile duct cancer, a thickened common bile duct wall was visualized as a 2 layer structure composed of hyperechoic and hypoechoic layers on US, and as a 3 layer structure on EUS. EUS could not differentiate PSC from diffusely invasive common bile duct cancer without mass formation. In both PSC and common bile duct cancer cases, liver biopsy specimens under laparo-scopy showed periductal fibrosis characteristic of PSC. It seemed that the periductal fibrosis was not always indicative of PSC.

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To examine the relationship between the lesion and the innominate groove, dye spread was perfomed in 19 cases of flat type lesions sized around 10 mm.Results were following : Three staining patterns were classified. Type 1: The innominate groove gets isterrupted at the lesion.Type 2: The innominate groove gets interrupted at the lesion, within which puncate stain in noted.Type 3: The innominate groove in extended to the inner part of the lesion. Histologically, there were 5 cases of type 1 consisting 3 cases of adenocarcinoma, and 2 cases of hyperplastic polyp, 9 cases of type 2 consisting 2 cases of adenocarcinoma, and 5 cases of severe atypical adenoma and 2 cases hyperplastic polyp, and 5 cases of type 3 consisting 2 cases of moderately atypical adenoma, and 3 cases of hyperplastic polyp. These results suggests that degree of atypia becomes severe in the order of type 3 to type 1 and that the present method is useful for presuwing the histology of colic flat type lesions sized around 10 mm.

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A 40-year-old man visited our clinic with complaints of nausea and vomiting. He has suffered from duodenal ulcer for approximately three years. Endoscopy revealed a H₁ stage duodenal ulcer and an esophageal mucosal bridge at 35cm from the incisors. The lesion was normal in color. Both sides of the mucosal bridge seemed fixed, but one side was dissected with forceps from the esophageal wall. Barium swallow showed a cord-like elevated lesion 5cm in diameter in the mid-portion of the esophagus. The specimen was composed of normal squamous epithelium and showed neither malignant nor inflammatory findings histologically. In relation to the etiology of the esophageal mucosal bridge, congenital abnormality, esophageal ulcer, esophagitis and esophageal submucosal dissection are mainly hypothesiz-ed in the literature.In this case, the etiology was unknown in its origin.

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We report a patient with herpetic esophagitis following renal transplantation. An endoscopic examination, performed because of epigastric pain, nausea and positive occult blood of feces, revealed diffusely scattered shallow ulcers, covered by a whitish exudate. Light microscopically the herpetic changes of squamous epithelium of ballooning degeneration, ground glass nuclei with eosinophilic margination and multinuclear giant cells were observed. A specific positive reaction with anti-herpes simplex virus was found. The patient responded dramatically to intravenous acyclovir, leading to a markrd improvement of the endoscopical findings. The patient is reported to underscore the importance of considering herpetic infection of esophagus in an imunocompromised host.

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A 51-year-old man who was pointed out the duodenal lesion in the third portion endoscopically, was admitted to our hospital for further examination for his depressed lesion. Endoscopic examination showed a well-defined depression with redness in color, so we highly suspected the duodenal carcinoma of depressed type. Biopsied specimen from the lesion demonstrated a well differentiated tubular adenocarcinoma and we diagnosed the lesion as an early duodenal carcinoma of depressed type. Pancreatoduodenectomy was performed. Resected specimen showed a depressed lesion, measuring 2.0×1.4cm in size, in the third portion of the duodenum. Histologically, a well differentiated tubular adenocartinoma was limited to the mucosa without lymph node metastasis. There is no case report of depressed early carcinoma in the third portion of the duodenum in the literature.

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A 51-year-old female, visited to our clinic because of abnormal uGI series. Abdominal plain X-P, endoscopy and endoscopic ultrasonography revealed a "phlebolite" characteristic of the present disease, a dark purple rosary-shaped process in a comparatively localized protuberant lesion having bridging folds in the fundus of the stomach and linear echo and strong echo having an acoustic shadow in an abnormal low echo, respectively. These preoperative examinations and peroperative findings enabled us to make a diagnosis gastric hemangioma, on which a wedge resection was performed. Pathohistological examination of the resected specimen revealed a cavernous hemangioma mainly involving the muscularis propria and partly the submucous layer and subserous layer, which was found coupled with thick, hypertrophied drainage veins. The incidence of vascular lesion in the digestive tract is low, and especially, angioma originating in the stomach is so rare that only 90 cases have been reported in Japan until 1988. Although the diagnosis of the present disease by endoscopic biopsy is difficult because of hemorrhagic risk, inquiry of its history and laboratory findings make the diagnosis easier. Especially, endoscopic ultrasonography will become more and more useful in the diagnosis of gastric hemangioma.

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A 83-year-old woman was admitted to our hospital complaining of right upper quadrant pain for one month. Ultrasonographic examination and computed tomography demonstrated a unilocular cyst 8cm in diameter at the head of the pancreas. ERCP revealed a slightly dialated main pancreatic duct, which communicated with the cyst. Puncture exudate in the cyst was serous and it showed high level of amylase, CEA and CA19-9. Following percutaneous drainage of the cyst, the sinus tract was serially enlarged by exchanging the drainage catheter up to the size of 16Fr. Through the sinus tract, endoscopic examination for the cyst was carried out using a cholangioscope (Olympus CHF type P20). On endoscopic examination, the cyst was found to have a smooth lining, and the histopathological finding of biopsy specimens revealed a true cyst of the pancreas. Percutaneous pancreatic cystoscopy in a useful method for the differential diagnosis of the pancreatic cysts.

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A 71-year-old male was hospitalized with fever. He experienced total gastrectomy with double tract reconstruction because of lower esophageal cancer five years ago and also cholecystectomy and choledochotomy was performed because of choledocholithiasis three years ago. Ultrasonography revealed obstruction of the common bile duct. Per-cutaneus transhepatic cholangio-drainage (PTCD) was done immediately. PTCD showedd two choledochal stones, 1.5cm in diameter. Endoscopic stone removal was performed with JF-IT10 (side-viewing endoscope). Fiberscope was inserted under fluoroscopy with less air insufflation. On some occasions, a biopsy forceps was used as stiffening tube. After endoscopic sphincterotomy (EST), stone extraction was completed with bascket catheter and balloon catheter. In patient with total gastrectomy, ERCP and EST were scarecely done because of limited success rate, but intubation may be f ascilitated by using various technics in some cases. We conclude that there is no contraindication to endoscopic surgery even after total gastrectomy.

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A 55-year old man was admitted to Iwate Prefectural Hospital with complaint of nausea and vomiting. Upper GI series showed partial obstruction at the second portion of the duodenum. A septum was outlined at the point of obstruction, with the contrast medium trickling through a centrally located aperture. Therefore, our preoperative diagnosis was congenital duodenal web in an adult. On January 23 in 1989, operation was performed by duodenotomy with excision of the web. On histology the duodenal web was covered by normal duodenal epithelium. Congenital duodenal web in an adult may be considered a very rare disease. Three cases have been reported in Japan. Once the diagnosis is made, surgical correction either by duodenotomy with excision of the web or a duodenojejunostomy provides excellent results.

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A 82 year-old man visited the Tsuruoka Kyoritu Hospital, with the chief complaint of anorexia and epigastric discomfort. Gastrointestinal endoscopy revealed an irregular depressed lesion at the posterior wall of the second portion of the duodenum. Histological examination of the biopsied specimen revealed adenocarcinoma. Pancreaticoduo-denectomy was performed. The resected specimen showed an irregular depressed lesion, measuring 1.4×1.2cm in diameter, located at the posterior wall of the second portion of the duodenum close to the papilla Vater. Histological examination revealed well-differenciated tubular adenocarcinoma confined to the mucosa, with no metastasis to lymph nodes and no vascular invasion. This case was the 45th case of the early duodenal carcinoma, and the 4th case of the depressed type reported ever in Japan.

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A case of ileal lipoma which was successfully diagnosed preoperatively is reported. A 60-year-old woman was admitted to our hospital because of mucous bloody stool. Barium enema revealed a round tumor at the terminal ileum where 30cm oral to Bauhin's valve. The tumor was considerably mobile and tended to intussusept (Figure 1 and 2.). Colonoscopy showed a smooth-faced ileal tumor covered with intestinal mucosa and a few erosions were seen on the suhface (Figure 3 and 4.). The computed tomography (CT) disclosed a well defined low density tumor. The CT number of the tumor was -85.3HU, which indicated that the lesion originated from fat tissue (Figure 6.). The hypovascular feature of the tumor was found on superior mesenteric artery angiography (Figure 7). A diagnosis of ileal lipoma was made and extirpation of the tumor was performed. The surgically resected specimen was 4.0×3.6×3.6 cm in size and diagnosed his-tologically as benign lipoma (Figure 8, 9 and 10.). There are few cases of ileal lipoma which were accurately diagnosed preoperatively, and the characteristic features of the medical imagings of the tumor were discussed.

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A 65-year-old man was admitted to our hospital with the chief complaint of back pain. Plain abdominal X-ray films revealed a marked gas retention with niveau in the small and large intestines (Figure 1). A long tube was inserted into the patient (Figure 2). X-ray examination using contrast medium through the tube showed a thumb's head sized filling defect near the ileocecal valve (Figure 3). Total colonoscopy was done and a pedunculated cystic tumor was observed on the upper lip of the ileocecal valve (Figure 4). Lymphangioma was suspected on the basis of endoscopic findings. The tumor was endoscopically resected (Figure 5), and no complications occured. It was 18×10×20mm in size. The gross finding of cavernous lymphangioma covered with the small intestinal mucosa was histologically confirmed (Figure 6). There were only 2 previous reports concerning lymphangioma on the ileocecal valve in Japan, Europe and America. Although the most cases of lymphangioma in the colon were sessile, all of the 3 cases on ileocecal valve were pedunculated. This fact was supposed to be a relationship of the frequent movements of the ileocecal valve. It was confirmed that endoscopic polypectomy for the elevated lesion on the ileocecal valve was safely perfor-med.

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A 31-year-old man who has suffered from muco-bloody stool, abdominal pain and body weight loss since 3 months staying in China. He was pointed out the abnormality of the colon revealed by barium enema in other hospital. There were multiple barium-lucent nodules with central barium fleck from the transverse colon to the recto-sigmoidal colon. Colonoscopy performed in our hospital revealed numerous aphthoid ulcers between normal mucosa. Fecal occult blood was positive. Although any bacterium could not be dedetected by stool culture, Shigella flexneri 2a was isolated from the culture of the colonic mucosa taken by biopsy. Histological findings were non-specific colitis with superficial erosion. Subjective and objective symptoms were rapidly improved and fecal occult blood also became negative by the oral administration of norfloxacin 600mg/day. Radiologically, colonic mucosa returned to normal 3 weeks after the treatment.

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Although modified Brown's method has been widely used as preparation for colonic examination, it is occasionally difficult for patients to swallow a full dosage of magnesium citrate and dietary restriction is required on the day before the examination with this method. Recently, polyethylene glycol electrolyte lavage solution (PEG) has been frequently used for cleaning the colonic lumen in many institutions, but this method afflicts patients very much, because it needs to take a large amount of PEG. For the purpose of improving the patient's compliance, the author proposed a method to clean the colonic lumen which does not need to restrict the diet on the day before the examination on the experience in 185 patients. Compliance of the proposed method by the patients was investigated by means of the questionnaires and the grade of cleaning of the colonic lumen was evaluated by both the colonoscopy and barium enema. The proposed method yielded excellent cleaning effects. This method was safe and simple to perform. Compliance, simplicity and safety of this method were fairy good. It was noteworthy that this method was very effective to clean the lumen of the ascending colon and caecum. These results suggest that the proposed method was useful for preparation of colonic examination in clinical practice.

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