To clarify the implication of Helicobacter pylori (Hp) for the mechanism of duodenal mucosal damage, we investigated the relationship between the presence of superficial gastric metaplasia (SGM) and frequency of Hp colonisation in the duodenal bulb. Detection of SGM (Alcian blue-PAS stain) and histologic diagnosis (Giemsa stain) for Hp colonisation were made using the biopsied specimen in 44 samples of 36 duodenal ulcer (DU) cases and in 16 samples of 16 healthy controls revealing no remarkable change in the duodenal bulb, endoscopically. SGM was found in 38 (86%) DU cases while only 8 (50%) in controls. Hp was detected from 90% of SGM in DU cases, 50% in controls but not found from normal duodenal mucosa. There was positive correlaton of quantitative grade between SGM and Hp. Polymorphonuclear cell infiltration and reduction of intracellular mucin were also observ-ed, when the biopsy specimen contained full amount of SGM and Hp colonised there. These histologic changes improved quickly with antimicrobial therapy. In conclusion, these results suggest that the presence of SGM and the Hp colonisation play a major role in the mechanism of duodenal mucosal damage.

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Worm-eaten appearance (WEA) is a form of endoscopic fine lesion closely related to Crohn's disease. This lesion can be observed with magnifying endoscopy in apparently normal mucosa. This WEA is considered to be a local immunological response to an etiological factor existing in the bowels. To elucidate the underlying pathophysiology, we conducted electron microscopic examinations and immunohistological studies using the peroxidase antibody method. Granulomata were detected at a high rate in regions with lymphoid hyperplasia. Many of the plasma cells in regions with WEA were found to be hyperfunctioning. The cells infiltrating into regions with WEA were mostly T cells with an imbalance of T cell subsets wherein Leu3a+ cells (helper/inducer T) became dominant over Leu2a+ cells (suppres-sor/cytotoxic T). These findings seem to represent immunohistological evidence that WEA is an endoscopic fine lesion due to immunological abnormality.

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To analyse thoroughly the peritoneoscopic pictures of the surface of the liver, it is necessary to understand its fine anatomy, or in other words, to know precisely the course and distribution of portal venous system. Finest branch of portal venous system is named as terminal portal venule (TPV), which usually end in the liver capsule and can be observed peritoneoscopically in combination with surrounding connective tissue as a grayish small spot of 0.1-0.3 mm in diameter. Classical hepatic lobule is circumscribed by these grayish small spots, descrived above. Hepatic lobular markings were observed in 86 out of 110 cases (78.1%) under magnifying peritoneoscope and mutual distances between grayish small spots were 0.2-2.0 (mean±SD, 0.76±0.25) mm. Histological reconstruction study on liver blocks obtained at autopsy or surgical resection revealed that almost all portal veins running f oward the liver surface connect with TPVs of the liver capsule in 4 cases, and end in the hepatic parenchyma in only 1 case. The mutual distances between superficial spots of TPV were 0.2-1.7 (mean±SD, 0.85±0.35) mm, which were compatible with mutual distances between grayish small spots observed at peritoneoscopy.

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Clinical evaluation of endoscopic ultrasonography on the qualitative diagnosis and possibility of endoscopic therapy was performed for 12 lesions of GI tract carcinoid tumor. The tumors were visualized as low-echoic mass in 8 lesions, and as relatively low-echoic one in 4. The tumor size ranged 4 to 15 mm in diameter, and 3 to 7 mm in thickness. The localization of the tumors was diagnosed as in both mucosal and submucosal layer in 10 lesions, and in only submucosal layer in 2; the diagnosis was correct in 9 cases. As a result, carcinoid tumors of the GI tract were visualized as mass lesions of uniformly low to relatively low echo ; they were localized adjacent to the second layer. They could be distinguished from lipoma and cyst by the echo level, and from leiomyoma based on the localization. Endoscopic ultrasonography was considered to be useful for the diagnosis of carcinoid tumor and the determination of indication of endoscopic surgery.

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We studied on the development of esophageal varices in patients with liver cirrhosis without special treatment for esophageal varices (Group 1, 78 cases) and with the recur-rence of varices in patients treated by esophageal transection (Group 2, 19 cases) and in patients treated by endoscopic injection sclerotherapy (Group 3, 26 cases). 1) Group 1; After one year, there was no change of the variceal grade in 90% patients with F₁ and RC sign (-). However 1.5 years later, the increase of variceal grade was observed in 50% patients with F₂. All of cases with F₃ showed positive RC sign and 67% cases developed bleeding within 1 year. 2) Group 2; There were a few cases who recurred within 2 years. 3) Group 3; On the average, 58% of cases recurred after 8 months and bleeding occurred in 27% after 13 months. 4) In all groups, the correlation between the development of varices and the impair-ment of liver function of Alb, ChE, Plt, PT was observed.

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Endoscopic topical injection therapy has been used as a therapy of first choice for hemorrhagic gastric ulcer, and excellent therapeutic results have been obtained. In some patients with this condition, however, hemostasis is difficult to achieve with this therapy. In such patients, we have recently begun to apply transcatheter arterial embolization (TAE). Here we report endoscopic findings, angiographic findings and the hemostatic effect of TAE in 12 patients with hemorrhagic gastric ulcer in whom endoscopic hemos-tasis was difficult to achieve. Endoscopic findings were divided into two types: 1) Dieulaf oy's ulcer (exulceratio simplex ; Es) or similar lesion in 6 patients and 2) deep, wide ulcer in the remaining 6 patients. In all cases, the ulcer was located in the area supplied by the left gastric artery. Angiography revealed contrast material extravasation in 7 (58.3%) of 12 patients. The ruptured artery was the parietal branch in 5 patients, the ascending branch in a patient and the mucosal branch bifurcating from the ascending branch in a patient. The rupture of the parietal branch was noted in 4 patients of the Es group and was a characteristic finding. TAE was performed in 11 patients, and hemostasis was achieved in 9 (81.8%). Of these 9 patients, 5 showed permanent hemostasis, 1 was operated after hemostasis and 3 died of severe underlying disease in spite of successful hemostasis. The remaining 2 patients received urgent operation because of re-bleeding. In the 6 patients exhibiting with contrast material extravasation, hemostasis could be achieved by firm embolization of the ruptured artery. Of the 5 patients without extravasa-tion, 2 showed re-bleeding after TAE. Some patients developed mucosal bleeding or erosion after TAE, but no severe complications were observed. These results indicate that TAE is effective for hemostasis in patients with hemorrhagic gastric ulcer if endoscopic hemostasis is unsuccessful.

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We report a rare case of pedunculated esophageal squamous cell carcinoma which was treated by endoscopic polypectomy. A 68-year-old male was admitted to our hospital because of nausea and vomiting. An esophagogastroduodenal endoscopic examination revealed a pedunculated polypoid lesion approximately 3 cm in size at 34 cm from incisors. An endoscopic polypectomy was performed since he was diabetic with serious renal dysfunction. The resected specimen was 27 × 17 × 7 mm in size and its histological examination showed moderately differentiated squamous cell carcinoma confined to the mucosa. Most polypoid carcinoma of the esophagus is histologically classified into pseudosarcoma or carcinosarcoma. To our knowledge, 9 cases of pedunculated squamous cell carcinoma of the esophagus have been reported in Japan and endoscopic polypectomy was performed in only 2 cases of them. Endoscopic polypectomy in this case seemed an useful therapeutic method for eso-phageal polypoid lesion, because no signs of local recurrence and metastases were found 26 months following polypectomy.

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We report a case of stomach lymphangioma that was diagnosed by ultrasonic endo-scopy and polypectomy. The patient was 60 year-old man who consulted us with epigastric distress. A cystic submucosal tumor was detected in the submucosal layer of the antrum by ultrasonic endoscope. Transendoscopic polypectomy was performed and histologic examination reveald the tumor as lymphangioma simplex.

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A 30 years old woman was admitted to our hospital because of severe acute hepatitis of type B. After 30 days of admission and therapy, we performed liver biopsy under laparoscopy. Four days after biopsy, she complained abdominal pain in right upper quadrant, and in the back. Jaundice was obviously developed, and fecal occult blood was positive. Laboratory data showed obstructive jaundice with elevated levels of bilirubin, alkaline phosphatase and γ-GTP. Abdominal US showed low density area in segment 5th where biospy was performed, dilatation of intrahepatic duct and choledochus, and high echo levels in gallbladder and common bile duct. Duodenal endoscopy revealed clot masses in papilla of Vater, and endoscopic retrograde cholangiography (ERC) disclosed lucent defects in the gallbladder and the common bile duct (CBD). The drainage by ENBD catheter was performed for the obstructive jaundice. On 2 days after ENBD, she again complained of abdominal pain, and the drained bile was bloody. Abdominal US showed dilated CBD. Under ERC, clot was found to be filled in the CBD and the ENBD catheter was clotted, and new catheter was inserted, resulting in the improvement of the obstructive jaundice. Hepatic angiography revealed pseudoaneurysm (3mm diameter) in S5th, and a diagnosis of a fistula between hepatic arteriae and bile duct was made. Then the amount of blood excretion through ENBD tube decreased gradually and the tube was gone after 3 weeks. Hemobilia is a rare complication of liver biopsy, but it should be taken into consideration when abdominal pain develops after liver biopsy. ERC and US are very useful for the diagnosis and follow-up of this complication.

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Two cases of coexisting adenocarcinoma and malignant lymphoma in the stomach were reported. Case 1: 68-year-old woman suffered from epigastralgia. Roentgenogram and endoscopic examinations revealed a large protruded lesion like Borrmann-1 type cancer in the lesser curvature of the antrum. A total gastrectomy was performed under diagnosis of gastric cancer, and hitological examination of the resected specimen showed subsequently the tumor of the antrum which was composed of papillary adenocarcinoma and malignant lymphoma, diffuse, mixed type. Furthermore, poorly differentiated adenocarcinoma was found in the posterior wall of the upper body independently. Case 2 : 72-year-old woman complained of tarry stool and anemia. Endoscopic examination was carried out and revealed a large ulcerated lesion like Borrmann-3 type cancer in the antrum with pyloric stenosis. A subtotalgastrectomy was performed for progressive bleeding and anemia. Post operative macroscopic examination demonstrated that the tumor of the antrum was consisted with two lesions. The one was Borrmann-3 like lesion in the anterior wall of the greater curvature and the other was also Borrmann-3 like lesion. Histologically, the former lesion was papillary adenocarcinoma and the latter was malig-nant lymphoma, diffuse, large cell type. We also reviewed reported cases of coexisting carcinoma and malignant lymphoma in the stomach in Japanese literature.

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A 75-year-old man was admitted on April 10, 1990 with a three-day history of abdominal pain, vomiting, and fullness in upper abdomen. The upper half of the abdomen was distended and there was a slight tenderness to deep palpation but no rigidity was noted. An upright plain X-ray showed elevation of left diaphragm and two distinct fluid levels is stomach. Upper GI series showed typical features of mesentero-axial volvulus of the stomach. Endoscopic examination revealed multiple ulcers in a rotated stomach. Blood analyses showed hypochloremia and metabolic alkalosis, which was caused by massive loss of gastric juice. Conservative treatment was successful but the volvulus recurred twice in five months after discharge. Subsequently, laparotomy was performed on November 6, 1990. The stomach deviated to the left and positioned in the left subphrenic space. A reduction of the volvulus and anterior gastropexy were performed. He was discharged on 23rd postoperative day. Two months after surgery, no recurrence of volvulus was observed endoscopically. Both X-ray and endoscopic examination seemed indispensable for the diagnosis of gastric volvulus.

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A case of mixed infestation of Ancylostoma duodenale and Necator americanus was reported. A-85-years-old female was admitted for deterioration of chronic heart failure with slight anemia and positive stool occult blood. Upper gastrointestinal endoscopy revealed many worms in duodenum, and we captured the worms by biopsy forceps. Worms were identified as Ancylostoma duodenale and Necator americanus. Mixed infestation of them is rarely reported. After admistration of pyrantel pamoate and ferrum, anemia improved and stool occult blood turned into negative. Hookworms infestation has been rare, but we must take them into account to be the cause of anemia.

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The cause of ulcerative colitis is unknown. To explain the etiology of ulcerative colitis, infectious agents, environmental factors, psychogenic mechanisms and immunologic disturbances have all been hypothesized as causes. Recent studies have presented the evidence of implicating immunologic mechanisms in inflammatory bowel diseases. We encountered a couple (30-year-old male and 27-year-old female) who were hospitalized because of mucous bloody stool. They were engaged their marriage in August, 1989 and recognized diarrhea simultaneously in September, 1989. Concerning HLA haplotype, male has A 24-DR 2 and female has A 24-BW 52-DR 2, which has been shown to be associated with ulcerative colitis in Japan. These cases seem to show the contribution of a immunologic factor, HLA type and psychogenic factors in the development of ulcerative colitis.

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Endoscopic treatment for early gastric cancer in 2072 patients treated from 1972 to 1991, with particu-lar reference to surgical applications, indications and endoscopic techniques, is reviewed. Among them, Early gastric cancer was resected in 788 (43%). Investigation of 10-year relative cumulative survival rate revealed that 97.69% survivors were pathologically negative for lymph node methastasis. Ten-year relative cumulative survival rate of patients in whom cancer cells remained intramucosal layer, i, e. carcinoma in situ, was 100%. We performed a retrospective study at our Univer-sity Hospital of the relationship of lymph node methastases to endoscopic type and tumor size, in 631 patients who underwent surgery for simple early gastric cancer. No lymph node metastasis was observed in the following patient groups : (1) those with protruded type of early gastric cancer and tumor size less than 2.5 cm in diameter, (2) those with the depressed type, lesion size less than 2.0 cm in diameter and no associated ulcer or ulcer scar, and (3) those with mixed type with lesion size less than 1.5 cm in diameter. Furthermore, we evaluated the technical aspects of endoscopic treatment in 91 patients with early gastric cancer. On the basis of both lymph node metastasis findings and analyses of the technical aspects of endoscopic treatment, that we conclude endoscopic treatment is useful in the curative treatment of early gastric cancer, is especially useful for small tumors less than lcm in size, with no associated ulcer.

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