A previous study suggested that quantitative texture calculations might establish effective indicators for quantitative differentiation of gastric cancer on endoscopic ultrasonography (EUS). In this report, we tried to study the quantitative diagnosis of gastric submucosal tumors on endoscopic ultrasonography by using texture analysis. Nine cases were studied, including 4 leiomyoma, 3 aberrant pancreas and 2 malignant lymphoma cases. The texture measure, we used, calculated the gray level difference (8 statistical parameters; mean gray level difference, contrast, variance, kurtosis, skewness, energy, entropy and P (0)). These three histopathological types of submucosal tumors evaluated by analysis of variance showed statistical significant difference in four parameters of texture calculations, and these differences of texture were supposed to demonstrate the difference in histopathlogical structures. As a result, these three types of submucosal tumors were differentiated quantitatively by this method.

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We assessed the accuracy yielded by endoscopic ultrasonography (EUS) in diagnosing the extent of spread from cancer arising in the hilar or extrahepatic bile duct. The results were as follows; 1) An intact bile duct wall exhibited three ultrasonic strata : The first hyperechoic layer was a border echo including and echo from the mucosa; the 2'nd hypoechoic layer corresponded to the fibromuscular layer and adventitia; the 3'rd hyperechoic layer represented the subserosa, serosa and the border echo; 2) The overall visualization rate of the bile duct cancer by EUS was 89% (16/18); 3) In the 16 patients whose primary lesion visualized, disarrays observed in any one of the ultrasonic strata were utilized to diagnose vertical infiltration or horizontal spread. When the patients were categorized into 3 groups related to depth of infiltration as 2 for Group I (m/fm/af), 14 for II (ss/se) and 0 for III (si), the diagnostic accuracy by EUS was 13/16 (81%) for all patients, 1/2 (50%) for Group I and 12/14 (86%) for II. The presence or absence of cephalad horizontal spread was correctly diagnosed in 12/16 (75%) and those of caudal spread in 11/ 16 (69%); 4) EUS clearly demonstrated direct infiltration to the serosa (s) by 7/9 (78%), gallbladder (ginf) by 3/4 (75%), pancreas (panc) by 3/3 (100%), duodenum (d) by 1/1(100%), portal vein (vs (Vp)) by 3/5 (60%) and hepatic artery (vs (Ah)) by 1/4 (25%). Liver metastasis (h) and malignant or non-malignant lymph node swelling (n) was demonstrated in 1/2 (50%) and in 15/16 (94%), respectively. EUS failed to visualize direct infiltration to the liver (hinf) that could be detected in 3/4 (75%) by conventional ultrasonography.

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During panendoscopy of the upper gastrointestinal tract, we occasionally encounter a circular or oval discrete bright red spot, approximayely 10mm or less in size on its lining. In close up views, this red spot is constituted of localized small vascular ectasia or angiodysplasia. In this study 230 cases of angiodysplasia observed in 10, 163 panendoscopies was investigated. A computerized data-base was utilized for selection of the cases and the diagnosis was confirmed on their photo-documentations. Nocases of Rindu-Osler-Weber disease was present. The incidence was higher in male than in female. Multiple foci were observed in 18.7% of the cases. Its endoscopic appearance was divided into a "hinomaru (sun flag) type" (Color Figure 1 and 2) and "akamaru (red circlet) type" (Color Figure 3 and 4) by the presence or absence of white halo around a lesion. The halo seemed to be caused by stealing of the blood stream. The hinomaru type" covered 43.4% of the cases and was more common in larger foci. Two lesions were observed in the esophagus (Color Figure 5) and 3 in the duodenum (Color Figure 6). The other 276 lesions (98.9%) were in the stomach especially in the distal two thirds (Figure 3). Any related diseases as described in literatures was not noted. Massive bleeding was not experienced in any case except one occasion of melena after biopsy. Two cases resembled endoscopically an early gastric cancer (Color Figure 7 and 8).

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The hemodynamic changes in portosystemic collaterals before and after endoscopic injection sclerotherapy (EIS) for the esophageal varices were studied by single photon emission CT (SPECT), scintiphotosplenoportography (SSP), and/or rectal administration of ¹²³I-iodoamphetamine (IMP) in 33 patients with liver cirrhosis. SPECT was performed for the intra-abdominal blood pool with ⁹⁹mTc(740MBq) autologous red blood cells (RBC). Using SSP by injection of 740MBq of ⁹⁹mTc-MAA into the spleen, flow patterns of portal circulation and portosystemic shunt index were evaluated. Portosystemic shunt index was calculated using the follow equation. Shunt Index = Counts of Lung/Counts of (Liver + Lung) × 100 In the case of rectal administration of I-123 IMP (TRP), shunt index was calculated using the same equation employed in SSP study. In SPELT study, before EIS, blood pool images of coronary vein were demonstrated in 26 of 29 patients. In 4 of 29 patients, short gastric vein, spleno (gastro)-renal shunt, or paraumbilical vein were demonstrated. After EIS, the blood pool of coronary vein was eliminated or decreased in 16 of 26 patients. In 2 of 4 patients, the pool of short gastric vein was decreased. In 3 patients, the blood pool of spleno-renal shunt or paraumbilical vein was increased after EIS. In SSP study, the coronary vein was visualized before EIS in 12 of 13 patients. After EIS, the coronary vein was disappeared in 9 patients and decreased in 2 patients. The shunt index was increased in all 8 patients after EIS. In TRP study, there was no consistent tendency of changes of shunt index before and after EIS. Therefore, it is considered that SPECT and SSP studies are clinically useful for evaluating the hemodynamic changes of portal circulation before and after EIS.

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We reported two cases of superficial esophageal cancer treated by endoscopical excision (mucosectomy). The first case was a 73-year-old male who had ischemic heart disease. Endoscopical examination revealed a superficial depressed type of esophageal cancer in the lower esophagus. There was a high risk in performing surgical resection of the esophageal cancer because of the condition of his heart. Endoscopical excision was performed using a double channeled fiberscope (Olympus GTF-2 T 10) without any complications. After 18 months, there was no local recurrences, but in the upper esophagus another lesion of dysplasia was found out. The second case was a 81-year-old male who had ischemic heart disease. Endo-scopical examination revealed a superficially elevated type of esophageal cancer in the upper esophagus. Endoscopic resection was performed without any complications. After 4 months, there was no local recurrences, but close to the treated area, another cancer of superficially elevated type was developed. Thus, the second endoscopic resection was performed. Seven months after the second procedure, there was no local recurrence. So, we think endoscopical excision (mucosectomy) is useful technic for the treatment of superficial esophageal cancer.

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A 83-year-old famale was admitted to the Hospital with dysphagia on July 27, 1989. Barium swallow showed a well-circumscribed circular defect in the middle part of the esophagus. Esophagogastroscopy confirmed the presence of a rounded, smooth, extramucosal mass surrounded with intact mucosa. Pathological diagnosis of the removed tumor was leiomyosarcoma of the esophagus. Although leiomyosarcoma of the esophagus is a very rare neoplasm, we sequentially observed growth of the tumor. A total of 64 reported cases of primary leiomyosarcoma of the esophagus were reviewed in the Japanese literature.

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A 61-year-old female with epigastric pain was admitted to our hospital because the symptom had not improved with medical treatment. Endoscopy of the upper digestive tract showed a benign ulcer on the lesser curvature of the gastric angulus. Four weeks later repeated endoscopy revealed a flat circular yellowish-orange lesion in the cervical esophagus. The lesion was diagnosed histologically as ectopic gastric mucosa by biopsied specimens. There were no findings suggesting malignancy. However, a DNA index of the lesion was 1.27, suggesting high biological malignancy. Ectopic gastric mucosa in the cervical esophagus is considered to be relatively rare in Japan. Since there have been some reports on such mucosa developing cancer, careful observation of the clinical course is needed.

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A case of the fundic gland polyposis which disappeared spontaneously was reported. The patient was a 53-year-old female and she was pointed out about 30-40 gastric polyposis distributed at the normal body mucosa by upper GI series roentgenography for mass survey. Because the polyps consisted of fundic glands histopathologically and no atrophy of fundic glands was found in the body mucosa, multiple polyps were diagnosed as fundic gland polyposis. About 10 months later, follow-up roentgenographic and endoscopic examinatios revealed that multiple polyps disappeared almost completely and hypergas-trinemia and decrease of acid secretion were also observed. Histopathological findings of the body mucosa showed atrophy and degeneration of fundic glands with marked in-filtraion of round cells, which was clearly different from the histopathological finding of the body at the first examination. Spontaneous disappearance of fundic gland polyposis is very rare and only 6 cases have been reported. The mucosal findings after disappearance of polyps have not been described and the mechanism of disappearance has still unknown. From the observation of the body mucosa after disappearance of polyps, it is suggested that the spontaneous disappearance in this case might be caused by the involvement with atrophic change of the body mucosa.

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A 76-year-old man was admitted to our hospital with right hypochondralgia, Ultrasonographic and percutaneous transhepatic cholangiographic examinations revealed a movable stone in the dilated common bile duct. X-ray examination of upper gastrointes-tinal tract demonstrated a duodenal diverticulum. By endoscopic examination two worms with pinkish color and lcm in length, were found in the duodenal diverticulum. The worms were endoscopically removed by biopsy forceps and diagnosed as Necator americanus. Pyrantel pamoate was administrated and the ova in stool disappeared. Later, the surgical treatment for the common bile duct stone was performed.

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A 58-year-old man with liver cirrhosis was hospitalized because of hematemesis and melena. Endoscopic examination revealed bleeding from serpiginous vein in the 2nd portion of the duodenum. Upper G-I series showed them as the protruding lesion with smooth surface. Venous phase of superior mesenteric arteriogram revealed the duodenal varices supplied from inferior pancreaticoduodenal vein. Endoscopic injection sclerother-apy (EIS) with 1% Aethoxysclerol and percutaneous transhepatic obliteration (PTO) were performed, but bleeding from it continued. An emergency surgery of varices ligation was done. Although there was no recurrent bleeding from duodenal varices after surgery, he died of massive bleeding from ruptured esophageal varices. The incidence of ruptured duodenal varices is low. Only 35 cases of duodenal varices have been reported in Japan. EIS or PTO for ruptured duodenal varices also resulted in a high incidence of rebleeding. We reported the management for rupture of duodenal varices.

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A 83 year-old male was admitted to our hospital complaining of epigastralgia for two weeks. Ultrasonography and CT demonstrated a cystic mass at the head of the pancreas and dilated biliary tract. Percutaneous transhepatic biliary drainage was done on the second hospital day, revealing a fistula between the common bile duct and the pancreatic cyst which was filled with mucus. Through the fistula, cholangioscope was introduced into the cyst and the internal surface of the cyst was found to be covered by villous projections. Based on the findings of the biopsy specimens, the diagnosis of mucinous cystadenocar-cinoma was confirmed.

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A 79-year-old female was admitted to National Chubu Hospital complaining of epigastralgia in February, 1989. Ultrasonography and computed tomography showed the common bile duct (CBD) stones, and gall stone pancreatitis was suspected. After per-cutaneous transhepatic biliary drainage, lithotomy by PTCS was performed. Although the CBD stones were completely removed, levels of serum amylase were increased 3 times after the lithotomy. Pancreatography revealed a pancreatic duct stone, which was also removed by cholangioscope. The stone in MPD was composed of similar elements of CBD stones. There was no elevation of serum amylase level after removal of the pancreatic duct stone. After consideration of increased levels of serum amylase in the present case, aberrant gall stones in MPD may be a cause of pancreatitis.

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A 70-year-old male visited to our hospital complaning of epigastralgia. He had been treated a neuralgia of the lower extremity with a large amount of analgesics. The initial endoscopic examination revealed a deep gastric ulcer on the posterior wall of the prepyloric region. Medical treatment brought abous a relief of symptom, but no improvement in endoscopic findings of gastric ulcer after 3 months. Follow-up endoscopy after 8 months revealed that this lesion had penetrated into the duodenal bulb forming double pylorus. X-ray examination of upper gastrointestinal tract also revealed a gastro-duodenal fistula communicating between the posterior wall of the pyloric region and duodenal bulb. He had been followed up endoscopically for these three years and no change in form of the double pylorus.

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We reported a patient with hepatocellular carcinoma (HCC) complicated by gastric metastasis. The patient was 62-year-old male. He first admitted with epigastric fullness and was diagnosed to have HCC because of a high titer of AFP (6, 400 ng/ml) and by ultrasonographic and computed tomographic findings. Gastroscopic finding of an antral lesion was compatible with Borrmann III type gastric cancer. The biopsied specimens showed adenocarcinoma and this patient was assumed to have double cancers. The autopsy revealed the gastric tumor to be metastasis of HCC. Intraarterial injection of adriamycin-lipiodol emulsion and transcatheter arterial embolization to the primary lesion in the liver also made regression of the gastric tumor. Malignant cells had disappeared in biopsied tissues of the lesion. The gastric tumor decreased in size and turned to appear an ulcer scar. We could follow these changes endoscopically. The cause of death was hepatic failure due to advanced HCC. Metastasis was extended from the gastric antrum to the papilla of Vater and involved the head of the pancreas and around the choledocus, so the liver was obstructively jaundiced. The metastasis of HCC to the gastric mucosa rarely occurs and such case as observed endoscopically the improvement of the metastasis of HCC to the gastric mucosa seemed very rare.

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