We studied on 146 cases of gastric ulcer scar lesions endoscopicaly. We compared with the conventional endoscopic observation and color change after spraying 0.02% epine-phrine. At first, we classified conventional endoscopic stages, such as red scar stage (S1) to R₁, R₂ and R₃ according to the redness, and white scar stage (S₂) to W₁ and W₂. Color changes after spraying epinephrine were able to classify into whole redness (P₁), partial redness (P₂), and palness (P₃). Color changes after pharmacoendoscopy were variable. In cases of chronic gastric ulcer, scar lesions showing strong redness remained redness even after spraying epinephrine. On the other hands, all lesions of the whitish scar (W₂) changed to paleness (P₃). But, in cases of scar lesins showing same color as surrounding mucosa (W₁) changed altogether into P₁, P₂ and P₃. Then, evaluation of the follow-up cases were performed. All acute ulcers after strip off biopsy were changed into P₃ within 6 months. On the other hand, chronic ulcers were still observed P₁ and P₂ in over half cases after 12 months. Relapse cases showed S₁, and S₂. But, it was remained red in all cases after pharmacoendoscopy. Based on the results, we thought that pharmacoendoscopy was available for endoscopic determination of gastric ulcer healing.

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We studied endoscopic and histological findings of 37 cases of submucosal invading cancers of the colorectum for the past three years (16 polypectomy cases and 21 surgical resection cases). Endoscopical characteristics of the submucosal invading cancers (sm cancers) were as follows-the size: about 80% of those cases ranging 10-29 mm, the surface appearance: about 90% of those cases having irregularity and reddish color, about 60% of those cases having tense & solid impression and disappearance of gloss, about 40% of those cases having central depression and asymmetry, and about 20-30% of those cases having fragility and easy bleeding. When sm cancers were divided into three categories-sm₁-sm₃ cancers-according to the cancer infiltrating level, sm₂ and sm₃ cancers were difined as those massively involving the submucosa (sm massive cancers), because they had more vascular invasion than sml cancers statistically. In conclusion, 1) Endoscopical therapy for sm massive cancers should not be done without care because of frequent vascular invasion. 2) The sm cancers of the colon were 10-29 mm in size, and those endoscopic findings were reddish in color, irregularity and tense & solid impression of the surface, disappearance of the surface gloss. 3) It was not always easy to judge sm massive cancers endoscopically, but the following 5 findings of the surface appearance were supposed to be useful for judging them; obvious disappearance of surface gloss, central depression, easy bleeding, marked irregularity and profound tense & solid impression. 4) The possibility of high risk group for reccurence or metastasis should be kept in mind when disappearance of gloss and central depression on the surface of lesion were found endoscopically.

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To clarify the wall structure of the duodenal bulb, endoscopic ultrasonograms of the bulb were compared to the histological findings in 10 cases of autopsied materials. Endoscopic ultrasonography (EUS) was performed in 32 cases with duodenal ulcer. The instrument employed was GF-UM3 and JF-UM3 (Olympus). The results were as follows; 1. Comparison of endoscopic ultrasonograms and histological findings of the duodenal bulb in autopsied materials. 1) In all cases, the wall of normal duodenal bulb was ultrasonographically recognized as five layers in its structure as seen in the other GI tract walls. 2) Hyperechoic sports were visualized in the second layer and thought to be composed of Brunner's glands. 2. Clinical study of EUS in cases with duodenal ulcer. 1) Ulcer depth in the duodenal bulb could be evaluated by EUS in almost all cases. In cases with duodenal ulcer at the healing or scarring stage in the endoscopic diagnosis, the fusion of the second layer and fourth layer could be recognized. 2) The destruction of the five-layer structure was visualized in the ridge with duodenal linear ulcer. Furthermore, hyperechoic and hypoechoic spots were mixed in the ridge. These findings have not been altered by follow-up study in 2 cases with ridge of the bulb. In conclusion, the present study suggests that recurrence of duodenal ulcer may often occur on the ridge. However, an additional study by EUS will be necessary in more cases with linear ulcer, to clarify the cause and characteristics of the ridge formation.

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We sorted out 51 lesions with flat elevations (28 lesions with adenoma and 23 lesions with early cancer) among 620 adenoma specimens and 113 specimens of early cancer obtained during the past 5-year at our department. All of flat elevations with more than 10mm in diameter were early cancer and in those less than 9mm, incidence of early cancer 26.3%. The distribution of flat type early cancers in the large intestine was similar to that of advanced cancer compared with Is, Ip type early cancers. We devised flat elevations into 5 subtypes according to the macroscopic findings; lesions with a sharp edge and smooth surface (type 1), lesions with a sharp edge and erosion (type 2), lesions with a dull edge and smooth surface (type 3), lesions with a dull edge and central depression (type 4) and lesions with a granular surface (type 5), and studied them histologically. The lesions with a sharp edge, irregular surface and superficial bleeding were frequently carcinomas and superficial bleeding was a common macroscopic findings of sm carcinoma. We suggest that many of the flat early cancers have already invaded into the sub-mucosal layer when grown to 10mm in diameter and morphologically have changed from type 1 lesion to type 2 lesion.

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A 53-year-old man was found to have two small submucosal tumors; the one is 0.7 cm in diameter in the cardiac region and the other 1.7 cm in diameter on the posterior wall of the upper body at UGI X-ray and endoscopic examination in February 1987. Since upper abdominal pain appeared in March 1989, he underwent endoscopic examination. The tumor in the cardiac region had grown up to a hemispherical protrusion, approximatery 5cm in diameter, with two deep, well-defined ulcerations, approx 1cm in diameter, on the top of the tumor. The tumor on the posterior wall of the upper body showed no changes from the previous study. Endoscopic ultrasonogram showed that the tumors were originat-ed from the 4th layer that was the proper muscle. The former was diagnosed as endo-gastric leiomyosarcoma and the latter was diagnosed as endo-gastric leiomyoma on microscopic examination of the operated specimens. In summary, cases of leiomyosar-coma coexisting with leiomyoma were only 4 including this one in Japan. Doubling time of leiomyosarcoma in this case was 3.2months. It is concluded that a short-term follow-up survey is important in patients with myogenic tumor.

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A case of spontaneous esophageal rupture which healed by conservative treatment was reported. A 59-year-old male admitted with hematemesis after repeated vomiting. A bleeding lesion in the left side of the lower esophagus was found on emergency esophago-scopy. Esophagogram showed leakage of contrast medium into mediastinum from the lesion. The lesion healed spontaneously only by fasting and administration of antibiotics. Endoscopic and radiographic observation revealed the healing process of the lesion. The rupture of the esophagus was closed rapidly by 17th day from the onset. Careful evaluation of the patient who has symptoms suspecting the esophageal rupture, such as hematemesis after vomiting, may increase the incidence of Boerhaave's syndrome. A small rupture of the esophagus can be treated conservatively, but a care should be taken not to lose an opportunity of surgical intervention, if necessary.

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We reported a case of Ménétrier's disease diagnosed with endoscopic ultrasonography (EUS), strip biopsy and ^99mTc-DTPA-HSA scanning after administration of albumin. A 35-year-old male was admitted with a chief complaint of pretibial edema. Labora-tory data showed hypoproteinemia and iron deficiency. Huge gastric folds were observed on an upper GI study and endoscopic examination. EUS showed huge gastric folds to be due to thickening of the 1st and 2nd layer of the gastric wall without any abnormality in other layers. The histopathological specimen obtained by the endoscopic strip biopsy revealed the huge gastric folds consistent with hyperplasia of the foveolar epithelium. To demonstrate the leakage of protein from the stomach, radioisotopic (RI) study with ^99mTc-DTPA-HSA after intravenous administration of albumin was performed. RI activity was present in the stomach and the small intestine on the sequential RI study, confirming the leakage of protein. This patient was diagnosed as Ménétrier's disease from the findings of EUS, strip biopsy and ^99mTc-DTPA-HSA after intravenous administration of albumin. These three studies were useful for the diagnosis of Ménétrier's disease.

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A 59-year-old man who had abdominal injury by traffic accident when he was 25-year-old, hospitalized because of work up for myocardial infarction occurred in December, 1989. Ultrasonography revealed an elevated mass with partial low echoic small lesions at the neck and body of the gallbladder. Endoscopic ultrasonography revealed distinct enlarged vascular channels in the body of gallbladder wall, and a small low echoic lumina located in the hepatic hilum. Therefore, the elevated lesion was diagnosed as gallbladder varices. Computed tomography, MRI and angiography also revealed gallbladder varices and cavernous transformation of hepatic hilum. It is thought that endoscopic ultrasonography is very useful in the diagnosis of gallbladder varices.

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A 20-year-old male was admitted to Toyota Memorial Hospital complaining of epigastric pain and nausea on August 1, 1989. Ultrasonogram and plain-CT revealed giant cystic lesions in the liver. ERCP showed enormously dilated intrahepatic bile ducts, and celiac angiographyy disclosed several arteries vertically branching from the compressed hepatic arteries. PTC showed cystic dilation of the common bile duct, hepatic ducts, and intrahepatic bile ducts. In the dilated hepatic ducts, several mucosal-tag like structures were found by subsequently performed PTCS. Biopsy specimens showed no malignancy. Total choledochotomy with cystectomy was performed and histological examination revealed fibrous thickening of the ductal wall and the mucosal-tag like structures containing arteriolles. Of 581 cases of congenital choledochal cyst reported in the Japanese literature from 1980 to January 1991, this is the first report of the choledochal cyst with mucosal-tag like structures. We concluded that PTCS and biopsy would be necessary for the further examination of congenital choledochal cyst.

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A 63-years-old man with Immunoblastic Lymphadenopathy like T-cell lymphoma had upper abdominal pain and appetite-loss after chemotherapy. Upper gastroduodenal endoscopy revealed polypoid lesions in which top was pale of the duodenal bulbus. Histological finding showed cytomegalic inclusion body in the glandular endethelial cell. We suspected that the poypoid lesions of the duodenal bulb might be the first stage of cytomegarovirus infection following to the ulceration. Many postmortem cases have been reported, but endoscopically diagnosed cases are rare. There is no report of the duodenal lesions, and this is the first case of cyotomegalovirus infection of the duodenum.

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We experinced 18 cases with duodenal injury which consisted of 16 cases of blunt abdominal truma (10 cases ruputure, 4 intraluminal hematoma and 2 contusion) and 2 cases of suicide. The patients were 14 males and 4 females. The mean age of male was 41.8 years old and of female was 30.8 years old. Unfortunatly, 2 of 3 cases of the duodenal ruputure died from other severe organ injury and other one case also died of a no initial adequate treatment. One case was diagnosed by an emergency endoscopy and a duodenography through the endoscope using water soluble contrast medium on shortly after admission. One case of duodenal hematoma was diagnosed and could evaluate the size of lesion and location by same method. We concluded that emergency endoscopy and duodenography through the endoscope using water soluble contrast medium were very useful to comfirm an early accuracy diagnosis and an adequate treatment for duodenal injury in an blunt abdominal traumatic cases.

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We reported two cases of rectal Crohn's disease. Case 1; 58-year old male, had anal pain on defecation and anal fistula. Endoscopy revealed a remarkable stricture and cobblestone appearance in the rectum. Histological finding of biopsy specimen showed epithelioid cell granuroma. Case 2 ; 31-year-old female, also had anal pain and fever. Barium enema and endoscopic examination revealed a remarkable stricture and cobble-stone appearance in the rectum. Biopsy specimens showed epithelioid cell granuroma. There were no remarkable finding in other G-I tract detected by barium enema and colonoscopy. Based on these findings, we diagnosed these two cases as rectal Crohn's disease. Rectal Crohn's disease is rare in Japan. During the past twenty years, fourteen cases have been reported. Thirteen cases of them were operated by lower anterior resection and Miles operation. Our two cases are diagnosed as rectal Crohn's disease and have treated by conservative therapy and been making statisfactory progress. It is suggested that endoscopy is useful in diagnosis of rectal Crohn's disease.

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Endoscopic sphincterotomy (EST), percutaneous transhepatic cholangiodrainage (PTCD) and applied therapeutic endoscopy were recently popular procedures in Japan. Although complications are decreased by improvement of instrument and technique, they occur more frequent than that of another procedures and they sometimes result in severe ones due to association with vascular injury. We experienced 4 cases with bleeding who developed vascular jnjury, however we succeeded in hemostasis by interventional radiology (IVR) such as the transcatheter arterial embolisation (TAE) and complete hemostasis was obtained. Including a case with jaundice, all cases were well after TAE. After hemostasis, progress of all of cases including one case with jundice were well and we thought that it was possible to stop the bleeding by super-selective TAE for patients with low hepatic reserve. Wherever invasive procedures such as EST and PTCD are carried out, it is important to prevent the complications with possible case. But when vascular injury occurred, angiography and some IVR, such as TAE should be initially selected.

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Endoscopic Ultrasonography (EUS) using an ultrasonic probe made by Olympus Co. was performed on 95 colorectal lesions. Normal rectal wall was visualized as 5-layered structure by the ultrasonic probe as clearly as by the ultrasonic endoscope (CF-UM3). The accuracy rate in the diagnosis of colorectal cancer invasion was 80% by the ultrasonic probe, and 90% by the CF-UM3. Because of the loss of echo, it was also difficult for the ultrasonic probe to judge the depth of advanced cancer invasion even when the probe was inserted successfully into a narrowing lumen. The ultrasonic probe showed lower sensitivity (33%) in the visualization of lymph nodes metestasis than the CF-UM3 (100%). The probe was inferior to the CF-UM3 in observation of submucosal tumors and extrinsiccom-pressions, but it was an excellent instrument for visualization of inflammatory diseases and small elevated lesions. EUS using the ultrasonic probe can be useful in the diagnosis of colorectal diseases with the improvement of its resolving power and loss of echo.

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