We investigated a clinicopathological study to know the feature of flat and depressed type gastric adenomas in 31 cases. These 31 lesions included 13 flat type in 13 cases and 18 depressed type in 18 cases. Fifteen lesions (83.3%) of the depressed type adenoma were detected by endoscopic examination. In endoscopic findings, depressed type adenoma was observed as slight redness with the unclear demarcation surrounded by relatively rough and large nodules. The base of the depressed area was flat, and the marginal swelling was smooth. On the other hand, only one lesion (7.7%) of the flat type adenoma was detected by endoscopic examination. According to the results, the flat type adenoma may have little change in the tone of color endoscopically. All of 31 cases were found in the pyloric gland area. The mean maximum diameter of the lesion was 5.1 ± 6.6 mm in flat type, which was significantly smaller than 11.4 ± 5.6 mm in the depressed type and 9.7 ± 1.2 mm in cases associated with carcinoma in adenoma. Cystic dilatation of atypical epithelial tubules in deep layer of adenoma was small and diffuse development in flat type. However, in the depressed type adenoma, they tended to be large, existing in the marginal area. Therefore, based on results, it could be sugested that depressed type adenoma devel-oped from caving of flat type from the view point of growing form.

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Endoscopic ultrasonography (EUS) was performed for 30 chronic pancreatitis cases and 70 normal healthy cases. A diagnostic accuracy of EUS was compared with conventional ultrasonography (US) and ERP in chronic pancreatitis, and the morphological change of the pancreas was compared with normal healthy cases and chronic pancreatitis. Results were as follows : EUS findings of the main pancreatic duct were consistent with ERP findings. EUS was hightly superior to US in the diagnosis of chronic pan-creatitis. Higt echo spots and roughnesses of internal echo pattern of the pancreas were easy to detect and irregularities of pancreatic margin were well finely delined in EUS. Mildly rough internal echo and high echo spots around the main pancreatic duct were seen only in normal high age group, and those with severe roughnesses internal echo with massive high echo spots were detected only chronic pancreatitis. But obvious defference was not seen between normal healthy cases and chronic pancreatitis cases in diameter of pancreatic parenchyma. The diameter of the main pancreatic duct was more increased in cases with chronic pancreatitis. EUS adds plentiful imformation on the structure of the pancreas.

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Recurrence of esophageal varices after endoscopic injection sclerotherapy was evaluated in 101 cases. Recurrence rate of varices in 60 cases with completely eradicated esophageal varices after EIS was only 8.3% duringa mean observation period of 3 years and 5 months. In contrast, among 27 cases with incomplete eradication of varices, recurrence was seen in 23 (85.2%) during a mean observation period of 2 years and 5 months. Endoscopically, recurrent varices after EIS presented with characterisitic fea-tures. There were two types of redness, one was so-called atypical red-color sign (ARC) which presented as diffuse small bubble like redness, and other was marked telangiectasia. The mean interval between EIS and retreatment were 9.2 months. 69.2% of recurrent varices were treated by intravariceal injection and the rest were treated by para-variceal injection.

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We studied on the effect of local injection of Aethoxysklerol (AS) for gastric wall, especially, on the submucosal arterial plexus in 33 mongrel dogs. Microangiography was performed in order to observe the course of the gastric submucosal vessels after injection of AS. Soon after injection of AS, marked edema appeared in the submucosal layer and an avascular area in microangiography was formed in the same extent. After 3 days, inflammatory cell infiltration was noted in the submucosal layer, and after 7 days, vasculitis and thrombus appeared extensively in the submucosal layer. The extent of the avascular area in microangiography after 7 days was little less than it of the avascular area which was formed first. After 14 days, fibrosis and organization of the arteries were formed in the submucosal layer, and the avascular area reduced slightly in the size. This study suggested that local injection of AS would be an effective method for emergent endoscopic hemostasis of acute hemorrhagic gastric ulcer and be useful for preventing the rebleeding.

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The influence of Cyanoacrylate and combined administration with Lipiodol in rabbit vein was studied basically. 1) Histological changes were observed 1, 3, and 9 months after injection of cyanoacrylate into the ear vein of rabbits. Cyanoacrylate produces foreign body reactions and was retained in the rabbits vein for a long term. 2) On the rapid injection of Cyanoacrylate into the inferior vena cava of rabbits (venous pressure : 6cmH2 O) polymerized coagulation was recognized instantaneously, but no adverse effects to the heart and lungs were recognized. 3) Coagulation was seen over a length of about 8cm when Cyanoacrylate was injected into the inferior vena cava of rabbits for about 3 sec. 4) The mixture of Cyanoacrylate and Lipiodol (1:1) got to the lungs via the heart when it was injected into the inferior vena cava. These findings indicate that cyanoacrylate, when used alone, obstructs the blood vessels for a long term, and it is unlikely to become a thrombotic substance when injected rapidly. However, it may migrate through the blood vessels and may obstruct the blood vessels in other organs when it is administered in combination with lipiodol.

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The healing process of the large artificial ulcers induced by the EMRT technique (endoscopic esophageal mucosal resection using a transparent tube) was evaluated by both endoscopic and histological examination. On experimental and clinical study, no serious complications such as bleeding and perforation were observed during recovery period from the large artificial ulcers. The postoperative late-onset perforation was not occurred in any cases. Re-epitherization of artificial ulcer was accomplished within three weeks with no stenotic changes. The newly regenerated mucosa was consisted of the four layers (epithelium, subepith-elium, muscle layer and adventitia) on about 2 months follow-up period.

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A new fiber optic CO₂ laser system was developed, which made it possible to apply endoscopic treatment. The probe for endoscopic applications is 2.3 mm in diameter and 20mm in minimum bend radius. The tissue damage of the canine stomach was observed after the CO₂ laser irradiation. It was considered that the optimum condition to radiate on the mucosal lesion was 5mm in distance, 5-10 watts in output power and total 5 seconds in irradiation time. On the basis of these results, 38 cases of digestive tract diseases including 13 early gastric cancers have been treated with CO2 laser, and satisfactory results were obtained. The endscopic CO₂ laser treatment is considered to be effecive for mucosal cancer of stomach and biliary tract diseases.

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We examined peritoneoscopic findings of six patients with severe type of acute hepatitis, then compared it with eight patients with fulminant hepatitis. There were no liver atrophy in peritoneoscopic findings in patients with severe type of acute hepatitis, whereas two patients with fulminant hepatitis showed liver atrophy. There were various types of depressions in all cases ; two cases showed fine mild depression, 1; fine severe depression, 2 ; extensive mild depression and 1; extensive svere depression. Similar depres-sions were also observed in fulminant hepatitis. In a patient with acute hepatitis severe type of which peritoneoscopic findings showed extensive severe depression, it took 5 months to normalize hepaplastin test. There were no correlation between clinical findings including ascites and coma and depression in liver surface, but exist a correlation of jaundice which persisted for a long time and liver surface depression in acute hepatitis and fulminant hepatitis.

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In 1980, Davis et al publishied a nonabsorbable nonsecretory lavage solution (PEG) for the colon preparation which was mainly constituted of polyethlene glycol and sodium picosulfate. Recently, the colon preparation with the use of PEG is well known as a superior method to usual ones like modified Brown's method. We have started to use it for preparation of colonoscopy from 1987. At the beginning, the original dosage (41 per person) was prescribed for each examinee. The lavage effect was perfect but almost all the examinees complained of the huge quantity of liquid. Some of them could drink 31 at most. But the colonic preparation of which both examiners and examinees are acceptable. As the colonic preparation of some cases who took only 21 of the liquid was very poor, we thought more than 21 would be needed for the preparation. To determine the appropri-ate colon preparation, we evaluated the acceptance of examinees by questionnaire (Table 2) and effectiveness of colon preparation of three groups (Table 1). Almost all the examinees felt PEG solution was hard to drink because of the large volume (Figure 1). Among the side effects of PEG solution, occurrence of chillness was less in group II and III than in group I signif icantaly. Also, there was a tendency that the occurrence of nausea was less in group III than in group I and II (Figure 2). There was no difference among 3 groups in effectivenes of colonic preparation (Figure 3). In conclusion, the procedure of group III is more excellent than others in the point of examinee's acceptance and its convenience that the preparation can be accomplished within a day.

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The double contrast method by endoscopic transpapillary catheterization in the gallbladder was performed in 19 patients with gallbladder disease. In a case, the double contrast imaging of the gallbladder provided clearer images than that of the conventional ERC and a fine reticular pattern of the gallbladder wall was obtained. In 15 cases, a fine reticular pattern of the gallbladder wall was not obtained, but the double contrast method was effective. The double contrast images in 2 of the remaining 3 cases were similar to the conventional ERC. However, it was ineffective in a patient with a small polyp. It is important that the bile must be aspirated as much as possible in order to detect small lesions. We used, therefore, a catheter with side holes and a metal tip so that bile can be sufficiently aspirated from the gallbladder. About 48 ml of bile was aspirated through this catheter. Moreover, a fine reticular pattern of the gallbladder wall could be clearly demonstrated by using barium sulfate as the contrast material. The technology of this method can be utilized for the diagnosis as well as cytological examination of bile sample obtaind from the catheter in the gallbladder. From the experience with this method, a new technique could be used as an effective method in making an accurate diagnosis of gallbladder diseases.

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It is well known as malignant cycle that early gastric cancer often changes its form from ulcerative lesion to scar. We report that a III+IIc type early gastric cancer developed protruding lesion without depressed lesion and changed to IIc+IIa type. A 79-year-old man was pointed out ulcerative lesion at the angular region of the posterior wall of the stomach by endoscopic examination. After administration of anti-ulcerogenic agents such as H2 blocker, the lesion improved completely for two months, then 4 months later we found the apparent protruded lesion at the same region. The specimen of biopsy obtained from the protruded lesion revealed well differenciated adenocarcinoma. After that, the protruded lesion suddenly decresed in size and the diagnosis of IIc+IIa type early gastric cancer was made. Resected specimen showed massive fibrosis in the submucosal layer and adenocarcinoma limited to the mucosal layer. From the result of histological study, we considered the protrude lesion consisted of cancerous cells.

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A 50-year-old man was admitted Fukushima Red Cross Hospital because of melena and general fatigue. Laboratory data revealed a disseminated intravascular coagulation (DIC) with severe anemia. X-ray examination of stomach showed multiple elevated lesions with ulcer on the greater curvature of the upper body. These findings were compatible with "bull's eye" sign which was radiologically characteristic for metastatic gastric tumor. Endoscopic examination revealed multiple reddish tumors with bleeding. Histopath-ological findings of the biopsied specimen of the tumor showed an infitlation of anaplastic cells in the submucosal layer. Computed tomography of his abdomen showed multiple nodular space occupying lesions (SQL) in the liver and diffuse large SOL in the spleen. Malignant tumor of the splenic origin was most suspicious, because the largest tumor located in the spleen. He died of pneumonia and necropsy of his hepatic and splenic tumor showed anaplastic cells similar to those in the gastric lesions. In some part of the splenic tumor, irregular vascular channels were noted. Immunohistological examination of the anaplastic cells in the splenic tumor showed positive stainning for Factor VIII-related antigen which is characteristic for hemangioma. Metastatic gastric hemangiosarcoma is very rare and gastrointestinal bleeding is characteristic for this disease since hemangioma is abundant in blood and is frequently complicated with DIC.

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The relationship of duodenal ulcer (DU) and gastric cancer (GC) was investigated for 36, 388 cases which under went endoscopy of the upper gastrointestinal tract in the period from 1976 to 1988 at Kanto-Teishin Hospital. DU in cases with GC confirmed by endos-copy at the same time and in the past were regard as DU associated with GC (DU+GC). Gastric remnant cancer after surgery for DU was excluded from this study. The incidence of DU, GC and DU + GC in these 36, 388 cases was 9.39%, 2.56%, and 0.15% respectively (Table 1). The distribution of age in DU+GC was as same as GC and about 10 years older than that of DU (Figure 1). The associated rate of DU in GC was 5.7% and that of GC in DU was 1.6% (Figure 2), and incidence of association in DU +GC_t is higer in male than in female (p<0.01, Table 3). Association of DU was significantly observed more often in early GC than in advanced GC (11.0% vs 2.80%, p<0.001, Table 2). This result may suggest that DU is difficult to observed or easily over looked when advanced cancer is present in the stomach. All of the DU_S were almost healed stage when GC was detected (Table 4). In 70% of the DU+GC cases both diseases were detected simultaneously (Table 5). Then it is quite unlikely that GC could be detected in early stage in the DU+GC cases because of repeat endoscopy for following up of DU. The most common symptom of the DU+GC cases when GC was diagnosed was epigastric pain and it is followed by gastro-intestinal bleeding. Clinical features of early GC associated with DU were compared with those with out DU in sex and age matched cases (Table 6). In the former, the depressed type was frequent (p< 0.01), presence of gastric ulcer in the cancer bearing stomach was more common (p < 0.01), and often locates in the gastric antrum. The reports on DU+GC in Japanese literature was summarized in Table 7. In early GC, in which DU is scarcely over looked, incidence of association in GC among DU cases coincided with expected rate multiplied by incidence of both disease in male, but GC among DU cases was same to the expected number in male but significantly less in female (Table 8). In conclusion presence of DU doesn't quarantee lower risk of GC at least in male.

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A 56-year-old male with esophageal cancer was referred to the department of radiol-ogy in our hospital for radiation therapy on Oct. 17, 1988 because he had multiple lymph nodes metastasis. For severe pain, 50mg of diclofenac sodium (Voltaren) suppository was used for 11 days, thereafter, 100mg of the suppository was used for 19 days. A massive anal bleeding occurred on Nov. 23, 1988, 30 days after the use of Voltaren suppository, and the patient was referred to our department. Endoscopic examination revealed an ulcer with coagulated blood in the distal rectum. Endoscopy, eight days after the first endoscopy, revealed a healed rectal ulcer. However, beating bleeding suddenly occurred from a bared vessel during endoscopy. Ethanol was immediately injected to the ruptured vessel and the bleeding was stopped. There had been no rebleeding but the patient died of esophageal cancer. This case illustrates that local injection of ethanol into a bared vessel is useful to terminate bleeding in acute hemorrhagic rectal ulcer.

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A 64-year-old female was admitted to our hospital because of massive anal bleeding. Colonoscopy with U-turned method in the rectum below the peritoneal reflection revealed a lobulated tumor occupying a half of the canal. A part of the surface of the tumor was black. The biopsy specimen of the tumor showed proliferation of atypical cells with prominent nucleoli. Melanin granules were observed in some of atypical cells. A diagnosis of malignant melanoma was made. Upper gastrointestinal endoscopy revealed a small protruding lesion on the tip of the fold in the greater curvature of the lower body of the stomach. The surface of the lesion looked normal mucosa but the center of the lesion had an erosion. Although pigmentation was not observed in the lesion, proliferation of the same atypical cells as in the anorectal tumor was observed on histological examination of the biopsy specimen. Therefore, a diagnosis of metastatic malignant melanoma of the stomach was made. Since hematogenous multiple metastatic lesions and extensive intraperitoneal infiltration were found at laparotomy, sigmoidostomy was performed.

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