従来の直視型大腸内視鏡における盲点や処置(生検及びポリペクトミー)困難な部位を克服する目的で斜視型内視鏡(オリンパス社製GIF-XK10(前方斜視45°))を使用し,直視型内視鏡(同社製CF-1T10I)と比較しその有用性を検討した.対象は直視型内視鏡使用群202例と斜視型内視鏡使用群52例,合計254例である.観察や処置に関しては斜視型内視鏡は正面視の範囲が広がり有用であったが,直視型内視鏡に比べて回盲部到達率が16.0～23.2%劣った.これに関しては,GIF-XK10は上部消化管用に開発された機種であるため彎曲角,有効長を従来の大腸内視鏡程度に改良することで回盲部到達率を高める事が期待できた.

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周波数7.5MHz,最大径φ3.4mmの細径超音波探触子MINIATURE ULTRASONIC PROBEのPRO-TOTYPE-1およびPROTOTYPE-2(オリンパス社・アロカ社製)を使用し,切除胃標本を用いた基礎的検討,ならびに食道,胃,胆道系疾患計10症例を対象とした臨床的検討を行った.PROTOTYPE-1は画像の安定性および解像力の両者において臨床応用するには不十分であったが,PROTO-TYPE-2はラジアル走査式超音波内視鏡GF-UM3(7.5MHz)とほぼ同等の解像力があると考えられ,臨床応用可能と考えられた.MINIATURE ULTRASONIC PROBEの利点は,消化管においては,通常の超音波内視鏡では検索困難な領域(幽門部近傍)や通常の超音波内視鏡通過困難な高度狭窄症例の検索を可能とし,小病変に対しては直視下にPROBEの位置を確認しながら画像描出を行えるという点に存在した.また,胆道領域においては,胆管内腔からの病変部描出にアプローチできるため,超音波診断の新しい展開が期待できた.改良点としては,従来の超音波内視鏡に比べて画像の恒常性が劣ることと超音波ビームの到達深度が浅い事があげられた.なお,病変部に探触子を接触させて画像描出するためには,近距離音場を考慮して,先端バルーンを装着する必要があると考えられた.

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腸結核(TB)の回盲部内視鏡所見を盲腸,Bauhin弁,回腸末端の各部位に分けて,クローン病(CD)を比較対象として検討した.対象はTB30例(活動性12例,非活動性18例)とCD47例である.盲腸のTasche形成はCDでは4%にしか見られず,一方活動性TBでは33%にみられ鑑別診断上重要な所見と考えられた.盲腸の潰瘍形態はTBでは極めて多彩であり潰瘍形態のみから診断可能であったのは9例中3例のみでありその他の6例では潰瘍形態のみからの診断は不可能であった.一方,CDでは13例中12例がcobble stone像を伴う潰瘍であり診断は比較的一容易であった.Bauhin弁の閉鎖不全はCDの2%に対して活動性TBでは58%にみられTBに特異的で診断価値の最も高い所見であった.これに反して,CDではBauhin弁上に潰瘍や炎症性ポリープがみられることがあり,炎症に起因するBauhin弁の狭窄もみられることがあった.このようにBauhin弁の所見はTBとCDで対照的であり,病理組織学的な両者の違いを反映しているものと考えられた.回腸末端ではCD,TBともに不整形潰瘍を示すことが多く,CDでも縦走潰瘍,cobblestone像を示すことは少なかった.すなわち回腸末端よりも盲腸の方がCD,TBともに両疾患の特徴像を示しやすいと考えられた.以上の点に留意し盲腸,Bauhin弁,回腸末端の所見をすべて詳細に観察すればTBの診断は大多数の症例で可能となりCDとの鑑別もほぼ可能になると考えられた.

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特発性食道破裂の3例を経験した.全例男性であり,平均年齢は49.7歳であった.主訴は腹痛2例,胸痛2例,背部痛1例,呼吸困難2例.1例は飲酒後に発症し,1例は基礎疾患に消化性潰瘍による幽門狭窄症を認めた.1例は初診時に縦隔気腫を認め2時間で診断.残る2例は入院後18時間,36時間に胸腔ドレーンよりの排液の性状より消化管との交通を疑い食道造影・内視鏡検査にて診断した.破裂部位は3例とも胸部食道下部であり,2例が左壁に,1例が後壁に発症していた.緊急内視鏡検査は本症診断の一次検査として有用であり確定診断には食道造影が最も有用と考えられた.

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症例は61歳女性.胃集検で胃体下部の病変を指摘され,近医にて胃粘膜下腫瘍として経過観察されていた.病変発見より約6年3カ月後に,心窩部不快感とタール便を主訴として当科に入院.内視鏡検査で胃体下部に凝血が付着した深い潰瘍を伴い,立ち上がりが急峻な赤色調の強い粘膜下腫瘍を認めた.CTで脂肪腫を示唆する所見が得られた.出血を伴った脂肪腫を疑い胃切除術を施行した.腫瘍は大きさ4.5×3.3×1.5cm,組織学的に脂肪腫であった.

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症例は63歳,男性.1989年6月1日肝腫瘤とAFP高値の精査を目的に当科入院となった.基礎疾患に肝硬変が存在し,腹部CTおよび肝動脈血管造影の所見は多発性肝細胞癌を示したので,肝動脈内SMANCS注入療法を2回施行した.しかし,後日遠隔転移をきたし効果は不良であった.9月18日胃の小潰瘍から出血し吐血をみたが,内視鏡上同潰瘍は急速に増大,中心陥凹を伴う粘膜下腫瘍の形態(牛眼像)に至るとともに,周囲には大小の類似病変が多発した.これらの病変は病理組織学的に悪性リンパ腫であった.　剖検では肝内に肝細胞癌とともに多数の悪性リンパ腫結節が存在しこれが胃へ転移したものと推定された.

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症例は20歳,男性.主訴は下血.内視鏡検査にて十二指腸下行脚に表面平滑,赤色調の山田2ないし3型の隆起性病変を認め,生検にて毛細血管性血管腫の診断を得た.諸検査では他部位には異常を認めなかった.出血源は本病変で,再出血の可能性もあると判断し,99.5%エタノール局所注入を施行した.以後,隆起性病変は消失し,出血も認められず,当症例に対し本治療法が安全かつ有効であると考えられた.一方,本邦における十二指腸血管腫の報告は5例と少なく,しかも何れも海綿状血管腫であり,十二指腸の毛細血管性血管腫は当症例が本邦初報告例と考えられた.

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症例は,70歳男性.全身倦怠感,臍周囲より右下腹部にかけての不快感を主訴に来院.下部消化管内視鏡検査にて回腸末端にびらん,小潰瘍を認め,小腸X線検査を施行したところ空腸に回虫を認めピランテル・パモエートにて駆虫した.その2カ月後下部消化管内視鏡検査を施行したところ,下行結腸に全長約5mmの白い虫体を認めた.その形態および虫卵像より蟯虫症と診断し,再びピランテル・パモエートにて駆虫し,以後経過観察中である.本症例のように,内視鏡的に蟯虫を観察した報告は過去10年間の医学中央雑誌にて調べ得た範囲にはなく,きわめて稀と考えられ報告した.

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従来,ペースメーカー植え込み患者に対する高周波による内視鏡治療は禁忌とされ,その報告はほとんどみられない.著者らは,ペースメーカーを装着した総胆管結石患者に,ペースメーカーの構造とその特性を考慮し,電気ベクトルの方向性,対極盤の位置を工夫し,緊急時の準備体制を整えることにより,安全に高周波による内視鏡的乳頭切開術を行い得た.現在ペースメーカー植え込み患者は急増しており,適応のある症例には積極的に試みるべき治療法と思われた.

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回盲弁上の潰瘍病変にはCampylobacter腸炎など種々の疾患が知られているが,今回便培養陰性で下痢,口内炎などの自覚症状なく大腸癌検診の大腸内視鏡検査(CF)で,回盲弁上のみにアフタ様非特異性潰瘍病変を有する2症例を経験した.2症例共に男性で大腸癌健診にて便潜血陽性を指摘され,CF施行.回盲弁上に数個のアフタ様潰瘍があり,便培養陰性で,ツ反応正常で下痢,口内炎等もなく,生検組織では慢性非特異性炎症像であった.サラゾピリン2.0g/day投与し,3ヵ月後のCFでは軽快を認めた.サラゾピリンが有効であり何らかの感染性腸炎や潰瘍性大腸炎(右側結腸炎)が疑われるが,現時点ではクローン病の初期やアフタ様大腸炎などとも区別すべき疾患と思われ,分類不能(unclassified)のアフタ様潰瘍と診断した.

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症例は21歳,男性.昭和63年3月19日難治性下痢を主訴として入院.注腸X線・大腸内視鏡検査で直腸下部に全周性隆起とその口側に下掘れ潰瘍を認めたが,生検では特異的所見は得られなかった.またその他の消化管には著変を認めなかった.その後全周性隆起は敷石状となり全周性狭窄を呈した.また数回の生検でも特異的所見は得られなかったが,瘻孔と直腸・肛門周囲膿瘍を認めたため直腸型クローン病と診断した.保存的なコントロールが困難なため双口式人工肛門を造設した.その後サラゾスルファピリジン・ベタメタゾン・メトロニダゾール・アザチオプリン等で瘻孔は閉じ狭窄及び潰瘍は改善したため人工肛門を閉鎖し現在経過は良好である.　本邦報告21例についてみると非手術的診断は容易ではないが予後は良好で最近では保存的にコントロールされた例が増加している.

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骨原発性悪性線維性組織球腫(以下,骨MFHと略す)からの膵転移をきたした稀な1例を経験したので報告する.症例は,31歳男性.昭和62年骨MFHと診断され,翌年広範囲切除術,人工膝関節置換術を施行された.　平成2年5月,腹部膨満感等を主訴に紹介され,精査のため入院した.各種画像診断では膵癌と診断し,エコー下膵生検で骨MFHからの転移を疑い,膵体尾部切除術後の病理組織で骨MFHからの転移性膵肉腫と診断した.

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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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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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