The endoscopic findings of reflux esophagitis were classified into two types (longitudinal and localized type) and five lesions (anterior, posterior, right side, left side, and circumferential lesion) on the basis of longitudinal and circumferential extent respectively in 24 progressive systemic sclerosis (PSS) patients and 26 hiatal hernia (H. H.) patients. Moreover, esophageal motility and salivary secretion were measured to clarify the patho-physiological correlation between the endoscopic findings, esophageal motility and secretory volume of the saliva. In the H. H. group, the incidence of longitudinal and localized type was same. In the PSS group, the incidence of localized type was higher (79.2%) than that of longitudinal type (p <0.05). In respect of circumferential extent of reflux esophagitis, the incidence of non-circumferential lesion was higher (79.2%) than that of circumferential lesion (20.8%) in the PSS group, whereas the incidence of circumferential lesion was higher (61.5%) than that of non-circumferential lesion (38.5%) in the H. H. group (x²-test, p<0.01). In the non-circumferential lesion, the incidence of right-posterior side lesion was higher than that of left-anterior side lesion in the PSS and the H. H. group. In the PSS group, significant correlation was not recognized between longitudial extent of reflux esophagitis and esophageal motility. Amplitude of primary peristalsis of lower esophagus in the right-posterior side lesion was lower than that in the left-anterior side lesion (p <0.05). Esophageal acid clearing time in the circumferential lesion was significantly longer than that in the non-circumferential lesion (p <0.01). Therefore, in the PSS group, correlation between circumferential extent of reflux esophagitis, and low amplitude of primary peristalsis and delayed acid clearance of esophagus were recognized. In the H. H. group, it was suggested that there was a correlation between longitudinal and circumferential extent of reflux esophagitis and decrease in salivary secretion.

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Diameters and numbers of nodules were studied during the development of liver cirrhosis (LC). Based on three-dimensional analysis of cirrhotic nodules in 6 autopsy cases with LC, the shape was considered to be nearly spherical, although nodules were partially connected to each other. In 163 cases of LC, diameters of surface nodules were laparos-copically measured. Diameters of nodules of advanced cirrhosis (code No. 500) increased 3.3 times in B type, 2.3 in non A, non B type and 2.2 in alcoholic type compared with those in precirrhotic stage (code No. 300). According to analysis of 114 of 163 cases, in which hepatic volume (HV) was measured by CT scan, HV of advanced cirrhosis was 30% smaller in B type, 25% in non A, non B type and 10% in alcoholic type than HV of precirrhotic stage. In 73 cases, numbers of nodules were calculated in use of HV, percentage of parenchyma and diameters of nodules, and numbers of nodules of advanced cirrhosis were marked low (1/40 in B type, 1/13 in non A, non B type and 1/12 in alcoholic type) in comparison with those of precirrhotic stage. It was supposed that after LC had been formed structually, hepatic necrosis caused nodule vanishing, and nodules which saved from necrosis enlarged by regeneration.

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Gastric ulcer scars were followed with electronic endoscopy (TGS-50 B of Toshiba-Machida) for 12 months at 3 month interval after apparent healing of the ulcers in 25 patients. The electronic endoscopic images of gastric ulcer scars were fed into an image analyser : SPICCA (by Japan AVIONICS), and transition of R, G, B intensity ratio to that of surrounding normal gastric mucosa was calculated. The transition of gland index (the ratio of the glandular area in the lamina propria to the area of regenerating mucosa) (Figure 2) was caluculated in 9 patients with SPICCA. The Red intensity of the scars was similar to that of normal mucosa in all course (Figure 3). The Green and Blue intensities were lower (76.0±15.3 and 75.8±14.4 respectively) just after healing. These intensities increased gradually, but did not reach a level equal to that of the surrounding normal mucosa even after 12 months (Figure 4, 5). On the other hand, the gland index was decreased initially and showed a minimum value after 6 months. Then, the gland index gradually increased, but it did not reach a level equal to that of normal mucosa even after 12 months, too (Figure 6). Therefore, we expect that gastric ulcer scars need over 12 months after apparent healing untill the complete restoration is achieved histologically. We could not distinguish strictly between the healed stages 1 and 2 objectively by color transition only.

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Ten cases with esophageal mucosal lesions, as esophageal ulcer, ref lux esophagitis, Mallory-Weiss syndrome, etc., were subjected to examine by use of endoscope attached with balloon on the tip. The balloon will be dilated by air-removed distilled water after setting appropriate position. The pictures obtained by balloon-endoscopy was compared with that of the routine endoscopy, and the results were as follows ; Balloon endoscopy was excellent compared with the routine endoscopy viewing from the decrease in the grade of the dead angle, the increase of the possibility of the frontal observation, and the observation of supressed view of the movement ; Fine structure of the mucosa however, appeared to be decreased in the balloon endoscopy comparing with that of the ordinary endoscopy.

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Problems, related to hard copying still image in the electronic endoscopes, are studied. An original chart is made while quantitatively comparing and studying an image obtained by phtographing the monitor and another image gained by inputting digital signal directly into the memory, in terms of resolution. The chart, consisting of 1, 1.5 and 3 lines in a colum of 1 mm width in vertical and horizontal directions, was made with an image analyzer. Six type of charts were printed out using a 35mm camera and pictrograhy 1, 000 (FUJI FILM). These 12 types of images were quantitatively compared and examined. A microdensitometer was used to have a density profile. The microdensitometer has a slit of 25 × 1, 000 μm specially machined. The lines of the created images were scanned by the microdensitometer in the arrow direction. The output wavef orms were recorded while defining their amplitudes with a A. Amplitude A₀ was defined for the scanning with the lines of 1 line/mm. A variable CTF (contrast transfer function) was defined by normalizing A by A₀ and used as an index of resolution. Resolution for a pitch of 1 line/ mm in both digital and still images were defined as 100%. Then the resolution of the digital screen in 3lines/mm was superior, 93.2% and 76% in horizontal and vertical directions, respectively. Conventionally used still image of a monitor screen was inferior to digital image in terms of resolution among hard copies of still images the electronic endoscopes. In order to make use of features of the electronic endoscopes, we have to introduce into the digital systems.

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Portal angioscopy was performed during hepatectomy for the intravascular observation of the portal vein in 12 patients with hepatocellular carcinoma and in 4 patients with metastatic liver tumor. The efficacy and the limitations of operative portal angioscopy for clinical use were investigated based on our clinical experience. Blood in the portal vein was completely diverted by an infusion of heparinized Hartman solution through a channel of the angioscope at a volume of 12 ml/min. A decrease of this infusion flow at 5 ml/min did not lead to any blood regurgitation. However, an infusion volume at less than 3 ml/min resulted in opacification of the optical view. The angioscope was easily inserted into the third-order portal branch using an angulation system. Both observation and removal of tumor thrombus was successfully performed angioscoplcally in 6 patients with hepatocellular cacinoma bearing a portal tumor thrombus (Vp₃). Though operative portal angioscopy is designed to observe the intravascular space of the portal vein, further technical improvements are desirable before this technique becomes a routine procedure.

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The ultrasonic probe is a new instrument for intracorporeal ultrasonography. Its maximum diameter is 3.4 mm at the tip, which contains a mechanical radial scan transducer (7.5 MHz, 360 degrees of image angle). Two procedures are available for the use of this new instrument. The one is a transpapillary insertion of the probe into the bile and/ or main pancreatic ducts through a duodenoscope. The other is a percutaneous transhepatic approach into the bile duct and gallbladder through a drainage track. Ultrasonography using this new probe was performed in 17 cases of the biliary and pancreatic diseases ; 9 of 17 with the transpapillary insertion and 8 with the percutaneous transhepatic approach. Images of the biliopancreatic system obtained by ultrasonic probe were clearly visualized, such as 3-layered structure of the wall of the bile duct and gallbladder, portal vein, splenic artery and vein. Tumorous lesions (even less than 5 mm in size) were clearly inspected and cancer extension was well diagnosed by this technique. Examination with the ultrasonic probe is a useful procedure in the diagnosis of biliary and pancreatic diseases.

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Methods for early detection of colon cancer curable by endoscopic surgery were evaluated in 156 aged subjects over 70 years old without any symptom or abnormal finding of the abdomen. Barium enema and endoscopy of the colon were performed in all subjects for screening. Morbidity and the detection rates of adenoma and cancer were markedly high (61.5%, 26.9% and 13.5%, respectively), and 30 to 40% of adenoma and cancer were found proximal to the descending colon. When findings of endoscopy and barium enema were compared, the false negative rate by barium enema was 54.4%, which was observed in many cases of polyp and 3 cases of early cancer. A high positive rate of stool occult blood test and high values of tumor marker were found in cancer cases. But, there was no significant difference between neoplastic cases (adenoma and cancer cases) and other cases (non-neoplastic cases and normal subjects). Thus, stool occult blood test and measurement of tumor markers (CEA CA 19-9) were useless for early detection of colon cancer in the aged subjects without abdominal symptoms and abnormal findings, and barium enema as the close examination was also inappropriate because of the high frequency of false negative findings. Therefore, we conclude that endoscopy is the most useful method for screening and treatment and strongly emphasize the importance of total colonoscopy in view of the specificity of development site of cancer in the aged subjects.

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We reported a case of viral gastritis due to cytomegalovirus (CMV). A 52-year-old woman developed a recurrent fever with general malaise. Gastrofiberscopy showed multiple short linear or criss-cross erosions measuring 2 to 3 millimeters in diameter on her gastric mucosa. Pathological study of gastric biopsy proved intranuclear inclusion bodies of Cowdry A type in the.mucosal epithelia and positive specific fluorescence of anti-CMV monoclonal antibody in the nuclei corresponding to the inclusions. She was diagnosed as having CMV gastritis by these findings with an increase in CMV IgM antibody titer. She recovered in about 20 days without antivirus therapy. It is very rare that a nonimmunocompromised host suffers from a cytomegalovirus infection.

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A 56-year-old male was admitted to our hospital for the further examination of the elevated lesion at the gastric antrum which had been detected by X-ray and endoscopic examination. Superficial elevated type of early gastric cancer or atypical epithelium (ATP) were suspected. The endoscopic biopsy specimen showed atypical lymphoid cells and malignant lymphoma of the stomach was suspected. The endoscopic ultrasonography (EUS) findings revealed the thickening of the only 2nd layer of the gastric wall without change of the third layer. Subtotal gastrectomy was performed. Histopathologically, the lesion was diagnosed as malignant lymphoma, diffuse medium cell type and the tumor invasion was limited to the mucosa. Anti-ATL associated antigen (ATLA) antibody was positive and hemogram showed abnormal lymphocytes after surgery. The final diagnosis was made as the gastric invasion of adult T-cell leukemia (ATL). Application of EUS for the local lesion of gastric mucosa of ATL has not been so far reported. EUS was thought to be useful to diagnose the degree of intermural infiltration and to examine the progres-sive process of malignat lymphoma of the stomach.

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A 78-year-old man who developed gastric candidiasis complicating leiomyoma of the stomach is described. A submucosal tumor at the cardia and an ulcer in the antrum were found by endoscopic examination. After treatment with H₂-blocker for the ulcer and broad-spectrum antibiotics for respiratory tract infection, the tumor developed an irregular ulceration on the surface and a yellow-white protrusion with coagula gradually appeared on the ulceration. The biopsy specimens from the base of the crater showed disarrayed cigar-shaped cells and those from the margin of the crater revealed infiltration of candida in the gastric mucosa, suggesting gastric candidiasis complicating leiomyoma of the stomach. Oral amphotericin B discontinued because of the side effects and intravenous miconazole was not effective. Endoscopic injection therapy with miconazole was started and after 11 sessions of the treatment (miconazole total 1, 700 mg), the ulceration and yellow-white protrusion disappeared. This is the first reported case of gastric candidiasis complicating leiomyoma of the stomach. Endoscopic miconazole injection is safe and effective for localized gastric candidiasis.

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A 56-year-old female was admitted because of a gastric protruded lesion on upper GI series. Laboratory data showed no abnormal findings. Endoscopy demonstrated a protruded lesion resembling submucosal tumor (SMT), 1cm in size, at the posterior wall of greater curvature of fundus. Biopsy of submucosal tissue was planned, but was not performed. Because endoscopic ultrasonography (EUS) performed before biopsy demon-strated that the lesion was not SMT but extragastric vessel mass. Celiac angiography showed an anuerysm of the splenic artery, 1.1 × 0.9 cm of size located at the posterior wall of fundus. We diagnosed an aneurysm of the splenic artery which oppressed the gastric wall and had the impression of a SMT endoscopically. An extragastric mass sometimes appears like a SMT. Recently several new methods such as ethanol injection have been developed to evaluate histologically SMT of the stomach. However, they sometimes have serious complications because the lesion could be an extragastric mass, especially vessel lesion in some cases. Ultrasonography and EUS are useful examinations to differentiate extragastric mass from SMT.

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A 54-year-old man was admitted to our hospital for having been found to have gastric polyp on X-ray in a medical check-up. Radiography and endoscopy with biopsy established a diagnosis of an early gastric cancer at the posterior wall of the angle as a protruded lesion which was accompanied by superficial spreading lesion.Pathologically, the lesion was classified as a signet-ring cell carcinoma of IIc+I type ; depth of invasion were submucosa and no evidence of lymphatic permeation, nor venuous invasion.The superficially spreading lesion was located at the posterior wall aspect of the lower body and was approximately 65 × 110 mm in size.The protruded lesion measured approximately 12 × 12 mm with a mucosal invasion and the muscularis mucosa was unaffected and unulcerated.Based on histological findings, we speculated that the lesion had become protruded due to proliferation of poorly differentiated adenocarcinoma in a medullary fasion at the middle and deep layer of the gastric mucosa, and at the superficial layer, signet ring cell carcinoma proliferated in a solid and acinar pattern without losing connection with each other. This is a very rare case of early gastric signet-ring cell carcinoma spreading in the superficial layer as well as growing in protruded form.

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A 77-year-old woman was admitted to our hospital with postprandial epigastric discomfort. A plain abdominal radiograph showed so-called pneumobilia. The ERC showed a stone in common bile duct, and accessory bile duct, of which end was opened in the parapapillary diverticulum. On surgery, an accessory bile duct communicated with right anterior lobe to parapapillary diverticulum, and gallbladder was completely absent. The final diagnosis was 1) right accessory bile duct, 2) absence of gallbladder, 3) opening of the common bile duct in the diverticulum, and 4) gallstone. A multiple anomalies of the bile duct was thought to be very rare, since no similar patient has been reported in the literature.

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A 79-year-old male visited our hospital because an abnormality in upper GI tract was pointed out at a mass screening. Upper gastrointestinal series X-ray and endoscopy revealed a thin lesion in the duodenum. The base of the lesion was attached to the mucosa of the second portion of the duodenum, of which surface was covered with the duodenal mucosa. Endoscopic polypectomy was done. Pathological examination revealed that the lesion consisted of normal duodenal mucosa, mucosal muscular layer, and submucosa including dilated vessels. We think that this lesion is Intraluminal duodenal protrusion (IDP) proposed by Inamoto et al in 1988.

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A 50-year-old male was admitted to our hospital because of fever and general fatigue. On the endoscopic examination, a tumor like lesion accompanied with ulceration was found in the posterior wall of the duodenal bulb. Histological examination revealed non-Hodgkin's lymphoma (diffuse large cell type). Computed tomography and bone scintigraphy were performed and revealed metastatic lesion in the liver, vertebrae, costal bone and iliac bone. The duodenal and liver lesions were disappeared with chemotherapy (VEPAM), bone lesions were not changed. Chemotherapy (ABEP) or irradiation were not effective for these lesions. Primary malignant lymphoma in duodenum is very rare. Only 46 cases were reported in literatures in Japan including our case.

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A 79-year-old male was hospitalized to our hospital, complaining of sensation of fullness in the right upper quadrant. Abdominal ultrasonography demonstrated the swelling of the pancreatic head and a swollen gallbladder with no sign of gall stones. Computed tomography showed swelling of the gall bladder and of the pancreatic head, and suggested abscence of the body and tail of the pancreas. Endoscopic retrograde cholangiopancreato-graphy (ERCP) demonstrated a short main pancreatic duct measuring a total length of 7.5 cm with a normal-appearing accessory pancreatic duct, and the common bile duct oppacified normal with complete obstruction of the proximal cystic duct. These findings supported a diagnosis of agenesis or hypogenesis of the body and tail of the pancreas associated with a cystic duct tumor. A surgical procedure including cholecystectomy revealed a tumor measuring 1.5 × 1.2 cm in size localized to the cystic duct as well as the enlarged pancreatic head associated with agenesis or hypogenesis of the body and tail of the pancreas. The cystic duct tumor was confirmed pathohistologically as adenosquamous carcinoma invading to the subserosa.Those cases of agenesis or hypogenesis (so-called agenesis) of the body and tail of the pancreas which were suspected by ERCP and confirmed either surgically or by autopsy were only 29 (including our present case) in the Japanese literature, and our case was the first associated with primary carcinoma of the cystic duct reported in the Japanese literature.

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A 74-year-old man complained of severe pain of the left lower abdomen and bloody diarrhea in March 1986. On admission, colonoscopic examination showed a large tumor that occupied the lumen, and five days after admission, sigmoidectomy was performed. The operative specimen contained a granular tumor and two longitudinal ulcers a few centimeters long. This patient was diagnosed as having a sigmoid colon cancer with obstructive colitis. Because of this disease, the patient was followed up. In October 1986, colonoscopic examination showed two bright red spots, one in the cecum and one in the ascending colon. A diagnosis of angiodysplasia of the colon was made (in July 1988 and in January 1990). Endoscopic examination was repeated. The shape of the angiodysplasia in the cecum had changed from round to irregular and its area had grown. The patient had not experienced rectal bleeding or anemia in 3 years and 3 months since the diagnosis of angiodysplasia. To the best of our knowledge, monitoring of asymptomatic angiodysplasia by endoscopy has rarely been reported.

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Three patients with anisakiasis of the colon were described. All were men aged 40, 59, and 45 years. The presenting symptom was slight epigastric, periumbilical, or lower abdominal pain. Leukocytosis was present in two patients. Upper GI series and endoscopy were unremarkable. Subsequent Gastrografin enema showed a stenotic change of the ascending colon in all the patients. Two patients also had multiple protruded lesions. Colonoscopy revealed a worm in the center of a reddish edematous area. Removal of the worm using a biopsy forceps resulted in a complete relief of the symptom. The significance of the urgent gastrografin study immediately followed by colonoscopy is worthy of note in the diagnosis and treatment of anisakiasis of the colon.

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We reported two patients with Crohn's disease initially having only aphthoid ulcers who developed longitudinal ulcers during the long-term clinical course. The first case was a 29-year-old man who was admitted to our hospital complaining of diarrhea, abdominal pain, and weight loss. Initial radiography and endoscopy revealed widespread aphthoid ulcers in the stomach, duodenum, small intestine, and colon. Histologic examination of the biopsy specimens showed non-caseating epithelioid cell granulomas, and therefore suggested to be Crohn's disease. Two years and 6 months later, radiography revealed longitudinal ulcer in the sigmoid colon. The second case was a 20-year-old woman who was admitted to our hospital complaining of diarrhea and abdominal pain. Initial examinations including X-ray and endoscopy revealed multiple aphthoid ulcers in the stomach, duodenum, small intestine, and colon. Stool culture was negative. Histologic examination of the biopsy specimens showed no specific findings, but clinical features indicated Crohn's disease rather than other inflammatory bowel diseases. Two years and 8 months later, repeated radiography revealed longitudinal ulcer in the ileum. These findings suggested that aphthoid ulcer seemed to be the earliest lesion of Crohn's disease.

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We carried out endoscopic examination for 31 cases with postoperative fistula, and evaluated clinical significance and limitation of the method. Observation was proceeded by using a choledochof iberscope with irrigation. In 13 cases, no cavity of abscess was observed, while recurrences of the cancer or the myxoma were histologically found in 2 of them. In the other 11 cases, the drains were removed and the fistulas were closed in 5.2 days on the average. In 18 cases with cavity of abscess, possible sources of infection like silk worm-gut as well as necrotic substances were eliminated. The drains were transferred to an effective site, and the cavities of absces were irrigated every day. As a result, the cavities of abscess faded out early in these cases in which the sources of infection were able to be eliminated. On the other hand, in cases with an anastomotic leakage or with a wide dead space, it took a longer period to close the cavity of abscess. In a case that osteomyelitis was the source of infection, the cavity of abscess was not closed. As for the technical problems, introduction of drainage was difficult in such cases that had a complexly bent and branched fistula. As mentioned above, the endoscopic examination of fistula revealed a certain limitation, but it would be of great significance for clinical use.

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