Forward-oblique viewing fiberscope (Olympus GIF-XK10) was used for colonoscopy, and its usefulness was compared with that of conventional forward viewing colonoscope (Olympus CF-1T10I) in terms of manipulation and observation. GIF-XK10 was tried in 52 patients, and CF-1T10I was tried in 202 patients. GIF-XK10 made it possible to keep the wider frontal visual field than CF-1T10I, and, consequently, was found to be useful for detailed observation and safety treatment. On the other hand, the insertion rate of GIF-XK10 into the cecum was 72.2-76.5%, being lower than that of CF-1T10I. However, forward-oblique viewing fiberscope is expected to be useful if the tip-bending range is widened and the working length is made as long as that of the usual specifications of colonoscope.

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An intra-corporal scanning ultrasonic probe (MINIATURE ULTRASONIC PROBE) used through a forceps channel of a conventional endoscope was developed cooperatively by Olympus Optical Co. and Aloka Co. We had an opportunity to use two kinds of MINIATURE ULTRASONIC PROBE (Prototype 1 and Prototype 2). The diameter of these instruments is 3.4 mm in both Prototype 1 and Prototype 2 and the ultrasonic frequency is 7-8 MHz in Prototype 1 and 7.5 MHz in Prototype 2. Subjects were a resected stomach with cancer in vitro study and ten patients with the upper G-I tract diseases in vivo study. As concerns the quality of the ultrasound images, Prototype 1 was inferior to the conventional ultrasonic endoscope (GF-UM 3; 7.5 MHz). However, it seemed that the ultrasonic resolution of Prototype 2 was almost the same as that of GF-UM3 (7.5 MHz). The followings were pointed out as important usefulness of MINIATURE ULTRASONIC PROBE. 1) approach to a prepyloric lesion or a severe stenotic lesion due to cancer which can not be easily achieved by conventional endoscopic ultrasonography, 2) visualization of a small lesion under endoscopically visual control, 3) visualization of a biliary tract lesion by scanning at the intra-biliary canal, While, there were some problems which should be improved in the clinical use of a MINIATURE ULTRASONIC PROBE, namely the improvement of the stability of ultra-sonic images and the penetration depth of the ultrasound. Furthermore, it was noted that the attachment of a balloon around the tip of the insturument was required in order to visualize ultrasonic images contacting the probe with the lesion.

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Endoscopic findings of tuberculosis (TB) the ileocecal region divided into each site of the cecum, Bauhin's valve and terminal ileum, were investigated in comparison with Crohn's disease (CD). The subjects consisted of 30 cases of TB (active type, 12 ; non-active type, 18) and 47 cases of CD. The sacculations in the cecum was noted only in 4% of CD cases, but in 33% of active TB cases. This finding was considered important for differen-tial diagnosis of both diseases. The ulcer form in the cecum was extremely varied in TB cases, and the diagnosis of TB with the aid of ulcer form alone was possible only in 3 out of 9 cases and was impossible in 6 other cases of TB. On the other hand, 12 out of 13 cases of CD had a cecal ulcer accompanied with cobble stone appearance, which resulted in relatively easy diagnosis of the disease. The Bauhin's valve insufficiency was seen in 2% of CD cases and in 58% of active TB cases ; this finding specific to TB had the highest diagnostic value. On the contrary, in some of CD cases, ulcers and inflammatry polyps were seen on the Bauhin's valve, and the stricture of Bauhin's valve due to inflammation was also observed. Thus, the findings on Bauhin's valve were contrasting between TB and CD, and seemed to reflect histopathological differences of both diseases. In the terminal ileum, the ulcers in an irregular form were frequently observed in both TB and CD cases, and there were few CD cases which had longitudinal ulcers or cobble stone appearance, It appeared that characteristics of both diseases were prone to be observed in the cecum rather than the terminal ileum. It was considered that careful examination of the respective findings on the cecum, Bauhin's valve and terminal ileum could lead to the definite diagnosis of TB in most cases, with resulting distinction from CD.

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We experienced 3 cases of Boerhaave syndrome. The patients were 3 males and mean age was 49.7 years. One case was diagnosed within 2 hours on admission becase of pneumomediastinum. The other 2 cases were suspected a communication between GI tract and thoracic cavity because of the findings of drainaged fluid in chest drainage tube, and diagnosed by esophagogram and UGI-endoscopy. We concluded that emergency endoscopy is an accurate initial examination for emergency patients complaining severe abdominal pain and/or chest pain in order to diagnose or rule out of Boerhaave syndrome. Esophagram was most useful method for diagnosis of Boerhaave syndrome.

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A 61-yaer-old female was admitted to our hospital with complaints of epigastric discomfort and tarry stool on the 14 th of November in 1989. The protruding lesion in the stomach was pointed out by upper GI X-ray examination of a group examination of August in 1983. A diagnosis of submucosal tumor (SMT) was made by endoscopic examination and followed for more than six years by a family doctor. During follow up period, the tumor developed gradually in size, but ulcer formation was not observed in the tumor. Endoscopic examination on admission showed a protruding lesion like SMT with two deep ulcers covered with coagula at the ulcer base in the lower gastric body. CT scan suggested a lipoma, because of a similar density of fatty tissue of the tumor. Partial gastrectomy was performed. On the resected specimens, the hemispherical tumor with two ulcers was 4.5 × 3.3 × 1.5 cm in size, and showed full development from submucosal layer of the stomach. Histologically, the tumor was composed of mature adipose tissue and diagnosed as benign lipoma.

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We report a case of metastatic lymphoma of the stomach whose growing course had been observed from the early stage. On July 1, 1989, a 63 year-old man was admitted to our hospital for further evaluation because liver mass with the elevation of AFP level had been detected. Liver cirrhosis existed as the background disease, and the findings of CT scan of the liver and hepatic arteriography showed multiple hepatocellular carcinoma, so SMANCS-injection therapy into the hepatic arteries was carried out twicely. Distant metastasis, however, occurred later and it resulted in poor prognosis after all. On September 18, the patient experiented haematemesis due to bleeding small gastric ulcer, which rapidly enlarged, and become the form of submucosal tumor with central depression (Bull's-eye lesien) and was surrounded by multiple similar lesions of varying size endoscopically. Pathological specimens from them revealed malignant lymphoma. Autopsy was performed. Not only hepatocellular carcinoma but also multiple nodules of lymphoma existed in the liver, and gastric lesions were thought to be developed as a distant metastasis from the latter.

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Twenty year old man was admitted for melena. Endoscopy was performed, and protruding lesion was observed at the descending part of the duodenum (Figure 1). Capillary hemangioma was confirmed by forceps biopsy (Figure 2). Hemangioma or hemorrhagic lesion was not found at the other sites. The lesion was suspected as the cause of melena, suggesting the possibility of recurrence of bleeding. So ethanol injection therapy was performed. These hemangioma disappeared 3 months later. The patient became well except transient abdominal pain upon the injection therapy. It seems that this is a safe and effective hemostatic therapy. Duodenal hemangioma is not common, and only 5 cases have been reported in Japan, and all of which are cavernous hemangioma. This is the first report of capillary hemangioma of the duodenum in Japan.

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Seventy-year-old man visited our hospital with general malaise and right lower abdominal pain. Lower intestinal endoscopy revealed some erosions and small ulcers in the terminal ileum. Small intestinal X-P was done for the purpose of further examination of erosions and ulcers revealing a worm of Ascaris lumbricoides of the jejunum. The patient was treated with pyrantel pamoate. Second lower intestinal endoscopy 2 months after the 1st endoscopy revealed the same erosions and ulcers in the terminal ileum and 2 white worms, about 5 mm in length, in the ascending colon. We diagnosed this worm as Enterobius vermicularis by the form and movement, and the egg. It is thought to be rare that Enterobius vermicularis is diagnosed endoscopically.

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Endoscopic treatment using high frequency waves has been generally contraindication for patients with implanted pacemakers. Therefore, there are very few reports of such treatment. In this study, endoscopic sphincterotomy using high frequency waves was tried for patient with the common bile duct stone and the results were successful without complications. The patient, a 58-year-old female has suffered from general fatigue and jaundice, and mitral commissurotomy for mitral stenosis six years and VVI type pacemaker implanta-tion surgically for Adams-Stokes syndrome five years ago were performed. She com-plained general fatigue and dull pain in the right hypochondrium since three weeks before consulting our hospital. On admission, obstructive jaundice was noted and percutaneous transheptic cholangiography revealed the presence of a calculus with 25 mm in diameter in the common bile duct. Endoscopic treatment by high frequency waves was attempted. Endoscopic shincterotomy using high frequency waves was safely performed in considera-tion of the structure and characteristics of the pacemaker, with taking care of electric vector direction, electrode position and ECG monitoring. Recently, as number of patients with implanted pacemakers is increasing, therefore it appears that endoscopic shincter-otomy using high frequency waves is useful treatment for patients with indication.

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Although enteritis induced by Campylobacter jejuni is known to cause a ulcerous lesion on the ileocecal valve, we encountered 2 cases of aphtha-like nonspecific ulcerous lesions (ANULs) without diarrhea and negative for fecal culture. They were noted to have fecal occult blood on mass screening, and underwent a colon f iberscope examination (CF), at which time several ANULs were detected on the ileocecal valve. They were negative for fecal culture and tuberculin test, and had no diarrhea stomatitis. Their biopsy specimen showed nonspecific inflammatory features. They were treated with Salazopyrin at 2.0 g/ day, and were found to be remitted on CF performed after 3 months. These 2 interesting cases of ANUL occurring on the ileocecal valve are herein reported.

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The patient was a 21-year-old man with a chief complaint of severe diarrhea on 19th of March in 1988. Barium enema and endoscopic examination revealed circular protruding lesions and undermining ulcer in the lower rectum. Rectal biopsy showed nonspecific inflammatory changes. There were no abnomalities in other parts of the GI tract. After that, the circular protruding lesions eventually changed to a cobblestone appearance and circular stricture developed. However, only nonspecific inflammatory changes were histopathologically detected by several biopsies. Perirectal abscess, perianal abscess and fisutula developed succesively and the rectal Crohn's decease was diagnosed finally. Because of difficulty of conservative treatment, sigmoid loop colostomy was performed. After salazosulf apyridine, betameth-asone, azathioprine and metronidazole were administered, fistula was closed and rectal stricture and undermining ulcer were improved. It was difficult to make a diagnosis for Crohn's disease by nonsurgical procedure in 21 cases which were reported in Japan. But recentry, there are increasing number of rectal Crohn's disease which responds to conservative therapy.

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A rare case of metastasis to the pancreas from malignant fibrous histiocytoma (MFH) of the bone was reported. A 31-year-old man who was diagnosed of MFH of the bone in 1987, and total replacement of the knee joint was performed in the next year. In May, 1990, he admitted with complaint of abdominal full sensation. A pancreatic tumor was revealed by ultrasonography. It seemed that the tumor should be diagnosed to be a pancreatic cancer by means of the following diagnostic imaging techniques such as EUS, ERCP, CT and angiography. But only the aspiration biopsy of the pancreas guided with US showed the findings of suggestive metastasis to the pancreas from MFH of the bone. Distal pancreatectomy was performed and revealed the lesion as a metastasis from MFH of the bone.

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A minute gastric cancer is the earliest cancer out of all types of early gastric cancer. Its detection and diagnosis are the final purpose of gastroenterological endoscopy. Due to the improvement of endoscopy, the frequency of its detection has been increasing, year by year. In October 1978, it was agreed at the 16th Congress of Japan Gastroenterological Endoscopy Society (JGES) that the size of a minute gastric cancer was less than 5mm. Such a minute size have to be measured under a microscope of the specimen, which is used to be far smaller than endoscopic measure-ment with stereoscopic electronic endoscopy. An early gastric cancer at the more earlier stage, as a minute gastric cancer does not reveal so called malignant findings, which are used to be observed by an ordinary endoscopic examination. Therefore, to detect and confirm a minute gastric cancer, biopsy is essential for minute changes of the gastric mucosa, such as slight hyperemia, discoloration and uneven-ness. An electronic endoscopy and pigment endo-scopy has been contributing to detect any minute change of the gastric mucosa. In spite of rapid increasing of detection of a minute gastric cancer, it has to be detected much more for contribution to the decreasing of mortality due to advanced gastric cancer, which has been the highest of all the malignancies, in Japan. The radical endoscopic treatment for a minute gastric cancer has become possible without surgical procedure. It needs strict diagnosis of size, extension and depth invasion of a minute gastric cancer for the treatment.

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A major advantages of ERCP and percutaneous transhepatic cholangioscopy (PTCS) exist in facilities of non-surgical therapeutic procedure. Endoscopic sphincterotomy (EST) has been contributed for a relief from choledocholithiasis, acute pancreatitis caused by choledocholithiasis, acute cholangitis, benign bile duct stricture and malignant obliteration. At present time peroral cholangioscopy becomes to be in practice for further investigation and lithotripsy using electro-hydraulic lithotriptor or pulsed dye laser. Successful outcome was also obtained by an application of extracorporeal shock wave lithotripsy for the choledocholithiasis up to 85% combined with EST. Success rate of bile duct lithotripsy has been achieved over 90 % so far, however a risk of complication was minimal in 7.2% of morbidity and in 1 0 or less of mortality. Difficult ES I has been existed, but could be treated combination of PTCS. ESWL and PCPS. Endoscopic decompression technique (EBD) offers a continuous internal drainage of bile with indwelling of large bore straight stent, 8F.10F, 12F, 14F, sized, to get better quality of life for the patient with inoper able obstructive jaundice. Success rate was 83 %, but late complication of clogging of the stent and cholangitis up to 30-50 %. We have a history of EST for 17 years. Follow-up study showed higher recurrence rate of bile duct calculi up to 11.4% to 25%. Accord-ing to Yamakawa's report, intrahepatic bile duct calculi were more commonly reccured 50% in 5 years. Most of the cases reccurred were significantly, associated with gall bladder calculi in situ. Recommendation could be made to receive surgical or laparoscopic cholecystectomy later on for those patients with gall bladder calculi in situ. First of all EST should be conducted for acute supurative fatal cholangitis as a first choice of treatment, and also for acute pancreatitis associated with choledocholithiasis.

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Quantitative analyses of the hemodynamic parameters in the organ microcirculation provide useful information for the better understanding of the pathogenesis and pathophysiology of various diseases. In this lecture, recent progresses in the methodological basis of the physiological study of the microcirculation are surveyed. Blood Flowmetry of the Microcirculation : Based on the two-slit method of Wayland and Johnson, various methods for the measurement of microvas-cular blood flow has been proposed. We have developed ten-channels' dual-sensor method to enable multiple flowmetery in the microvessels. Visualization of the Formed Elements : Fluores cent traces such as fluoresceins and acridines enable selective staining of the formed elements of the blood. thereby their dynamic behavior in the microcirculation are made to be visualized under a fluorescent intravital microscpe system. A few examples of the application of such techniques to the study of dynamics of the platelet thrombus formation and rheological analysis of the leukocytes behavior are presented. Visualization of the Mass Transfer Process : Fluorescent dyes can also be used as tracers for the transvascular mass transfer process. We have attempted to visualize dynamic processes of the mass transfer from microvessels through interstitium to microlymphatics. The augmented leakage of the high molecular weight substances at the site where diapedesis of the activated leukocytes was observed was also demonstrated.

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It is said that in our century, the appearance of the lasers was, in the area of scientific techniques one of the most important discoveries. The introduction of lasers to endoscopy, with all their special characteristics such as the coherence, targeting ability, high power, high intensity, conver-gence, high interference, ultra short light pulse gen-eration and other unique qualities, provided a useful and powerful mean for the diagnosis and treatment of cancer. We are reporting a recapitulation of the research done on the endoscopic use of lasers. In the field of diagnostic approach the cancer's fluorescence was discovered. When we irradiated an excised specimen of gastric or colon cancer with a 514.5nm argonlaser beam, we observed, through a VO -55 filter, the fluorescence corresponding to the can-cer focus. We found two types of fluorescence, a yellow-orange and a red one. In the case of early gastric cancer, the IIc group showed a yellow-orange fluorescence which was often significantly stronger than the intrinsic fluorescence of the normal mucosa. On the contrary, it was found that in the case of the elevated type of early gastric cancer its fluorescence was lower than that of the normal mucosa. Also a red fluorescence was often observed in decayed parts of colon cancer. In order to investigate that fluorescence we measured the fluorescent spectrum of a cancer tissue using a fluorescence analyzer. The yellow-orange fluorescence observed in the cancer focus, showed a biphasic spectrum at 5$0nm and 600nm a pattern similar to that of the normal mucosa. At the histological examination the fibrotic compo-nent of the muscularis mucosa as well as the inner elastic layer of the vessels showed a strong yellow fluorescence. The existence of the muscularis mucosa at the area of the mucosal lesion may be the source of the strong fluorescence that can be detected in the undifferentiated, depressed, early gastric can-cer focus. On one hand, the red fluorescence had a peak at 630nm and we supposed that it looked like the fluo-rescence of the porphyrin derivatives. In order to detect and to analyze the fluorescence spectrum we created a laser beam transporting system and we tried a variety of analyzers. In vivo, white coat, mucus, bleeding and other factors have a great influ-ence on the intensity of the fluorescence thus dimini-shing it and providing poor results. Till now the usefulness of its clinical application has not been evaluated. We started using YAG-laser tissue coagulation as a therapeutic method. The elevated, differentiated type of early gastric cancer, less than lcm, showed a 100% 5-year survival rate in contrast to the depressed, undifferentiated type of early gastric can-cer which showed a high rate of recurrence and demanded a retreatment (Table 1). Concerning the problem of metastasis to the lymphnodes, we found that the early, differentiated adenocarcinoma less than lcm, limited to the mucosa (ul-), was not accompanied by lymphnode metastasis (Table 2 ). If we seek a complete cure we have to look for a small gastric cancer. In order to achieve the complete tissue coagulation, we investigated, both basically and clinically, the efficacy of thermotherapy. Using nude mice, bearing tumor from implanted cancer cells, we evaluated the type, the distance and the temperature of the laser, the adjuvant cancer drugs, the HPD treatment as well as various other factors; we developed the equipment and started using it clinically. As a result the single use of lasers proved to be not satisfactory and in its place, a combination of photoradiation therapy and adjuvant chemotherapy was shown to be effective (Table 3). Recently, HPD, photophrin I and II, metal porphyr-ine derivatives, from pheophorbides, the pheophor-bide A, PH1126, from phthalocyanines, the zinkphth-alocyanine made their appearance and are under basic research investigation.

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In a gastric mass survey with photofluorography performed on 22, 313 male office workers over 40 years of age, 1, 071 cases of duodenal ulcer (DU) were detected. These cases were scheduled to be followed up every 6 months with endoscopy and without any anti-ulcer drugs. We are able to follow up 624 cases for 1 year and 251 cases for 4 years. The ulcer activity during this period was analyzed in connection with each cases' background. One fourth of ulcer with crater at initial endoscopy were healed, and one fourth of ulcer scar relapsed at 12 months. During 4 year follow-up period, 58% of active DU at initial examination healed at least once, and 53% of red scar and 15% of white scar at initial examination relapsed. Multiple and linear DU showed significantly less healing rate and more relapse rate than single DU. Regarding the relative risks, the cases with a history of previous treatment, amoking and high serum pepsinogen I showed higher ulcer activities during trial period.

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Superficial type early colorectal cancers (SECC) are so defined as early cancers composed of horizon-tally growing cancerous glands. When the glands are higher than the normal crypt, the lesions are II a (flat elevation) ; when lower, II c (depressed), and when the height of them are equal, II b (even, flush). The top of the lesions is flat regardless the height of them. The SECC are pure in figure (II a, II b, II c) in their early stage, they gradually show marginal elevation owing to the collision of horizontally growing glands and normal glands. Colonoscopic findings of SECC sometimes differ from macroscopic findings. Macroscopic findings tinged with microscopic features are to be adopted, because endoscopic picture may differ according to the volume of air. Moreover, the SECC are defined by the height of cancerous crypts. Superficial cancers are important because of their rapidity in which they penetrate the mucosal muscle. The sm ratio (smm+sm) of SECC is higher than other type of early cancers when small in size (Table 1). There exists no difference in the overall sm ratio between the SECC and sessile early cancers. One reason for that is SECC metamorphoses to sessile lesions due to the swelling up of submucosal cancer-ous volume. The diagnosis of SECC is difficult. In the very early stage, only the change of color is the due to the detection. When they are around 5 mm or more, some characteristic features for SECC are noticed. They are marginal elevation (II c ± II a, II b + II a, II a + II c) and collection of tiny white plaques. In the future, the diagnosis of SECC is expected to be earier by the introduction of scopes which enables the screening and manifying ability. Thye proto type of such scope is already in practical use. The asteroid (starfich-like) findings by the magnifying scope at the margin, particularly of the depressed type, is impor-tant in the diagnosis of SECC.

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The modern concept of GERD did not emerge until 1935, when Winkelstein suggested that esophagitis was caused by the action of gastric juice. The term reflux esophagitis, however, did not appear until 1946, when it was introduced by Allison. In the 1950s, GERD was thought to be caused by abnormal ana-tomic, mechanical factors associated with a sliding hiatal hernia. At the same time, many reports appeared confirming the existence of a lower eso-phageal sphincter (LES) that maintained a pressure barrier between stomach and esophagus. In the 1960s, the concept became widely accepted that the major determinant of GERD was "LES incompetency" caused by a feeble or atonic LES. Beginning in the 1970s, the cumulative findings carted doubt that a single factor, such as low resting LES pressure, could universally account for GERD production in all patients. After that, the consensus emerged that GERD is caused by a multifactorial process. The multiple determinants in the pathogenesis of GERD are described by Dodds as follows: 1) efficacy of antireflux mechanism, 2) volume of gastric con-tents, 3) character of refluxed material, 4) efficiency of esophageal clearance, 5) resistance of the eso-phageal mucosa. In these determinants, GER and acid clearance are major factors in the patho-physiology of GERD. I) Mechanisms of gastroesophageal reflux Three mechanisms associated with GER were revealed: 1) transient LES relaxation, 2) intraab-dominal pressure transients, 3) spontaneous free GER. Transient LES relaxation accounted for greater num-ber in controls than GER patients. The latter two mechanisms were easily associated with a low resting LESP of GERD patients. II) Gastric contents In order to cause esophageal epithelial changes resulting from GER, the refluxed materials, such as gastric acid, pepsin, and bile, must have some potency to injury. However, there was no significant differ-ence between controls and GERD patients in analytic studies of each materials. In regard to the develop-ment of GERD by Helicobacter Pylori (HP), no corre-lation between the presence of HP and esophagitis was found. III) Acid clearance Delayed esophageal acid clearance exists in GERD patients, that is caused by impaired primary peristal-sis, sleep, or insufficiency of LES relaxation. IV) Esophageal mucosal resistance The ability of esophageal mucosa to withstand injury and undergo repair may be related to mucus, bicarbonate ions, and intercellular junctions. V) GER in patients with mucosal discoloring type The severity of GERD in these patients is mild. The incidence of GER episodes in the patients was higher than normals according to our results of 24 hour pH monitoring. It is difficult to distinguish this type from the scarring stage of erosive ulcerative GERD by endoscopy.

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