Endoscopic ultrasonography (EUS) was performed in 71 patients, and the findings were compared with the macroscopical and histological findings. Submucosal tumors were treated in 32 patients surgically (n=27) or endoscopically (n=5). Histological diagnosis was made on 71 lesions from surgically or endoscopically resected specimens, or bioptic specimens (n=39). Tumor size, tumor shape, growth pattern of the tumors were compared with EUS findings and macroscopical findings. Internal echo pattern and histological findings were compared, retrospectively. EUS measurement of the tumor size was made in two directions, length-and-height or width-and-height. EUS data were almost identical to actual measurement from the resected tumors, and the error was less than 10mm. Tumor shape was correctly diagnosed by EUS in 27 of 32 lesions. Tumor growth pattern was classified in correlation with 4th layer of EUS or muncular layer, and EUS diagnosis of growth pattern was correct in 26 of 32 lesions. Internal echo patterns, classified into 5 types were compared with the histological findings. Eighty-seven percent of submucosal tumors (SMT) with "hypoechoic" pattern were leiomyoma. Fifty percent of the tumor with "mixed irregular" echo pattern were malignant. Single criteria derived from EUS findings, such as tumor size, tumor, shape or growth pattern of the tumor can not lead to an accurate diagnosis of malignant SMT, when analyzed retrospectively. To improve the diagnostic accuracy of EUS in differentiating malignant tumors, such as leiomyosarcoma or leiomyoblastoma, we postulate "malignant sign (MS)" from the combination of EUS findings. When MS assigned to 1) tumor larger than 20mm, with intermediate or mixed irregular echo pattern, or 2) tumor larger than 40mm, with hypoechoic pattern, 12 lesions were true positive and 49 true negative. False positive and false negative case were 1 and 12, respectively. Sensitivity of MS in diagnosis of malignant tumors was 92% and the specificity was 84%. EUS diagnosis of SMT was accurate in measuring its size, shape and growth pattern. Internal echo pattern reflects its internal structure. MS derived from the combination of tumor size and internal echo pattern is highly sensitive and specific in the diagnosis of malignant SMT.

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We tried to study automatic diagnosis of gastric tumors with endoscopic ultrasonography, by evaluating the calculated texture parameters on discriminate analysis. We studied differential diagnosis of gastric submucosal tumors and diagnosis of fibrosis and stroma on gastric cancer cases. In the former, eleven cases of gastric submucosal tumors were studied, including 3 aberrant pancreas, 6 leiomyoma and 2 malignant lynphoma, and in the later, 9 gastric cancer cases were studied, including 4 cases with fibrosis, 2 medullary type cases and 3 intermediate type 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)). The results of discriminate analysis were as follows : the discriminate rate was 61.5% in the former and 69.0% in the later. The discriminate rate, 61-69%, was important, because the results of discriminate analysis were introduced by evaluating only the internal echo of tumors regardless of the irregularities of layer structure of gastric wall, under ordinary condition on endoscopic ultrasonography. We concluded that to make the automatic diagnostic system on endoscopic ultrasonography would be possible by improvement of this method.

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Two hundred and seventy-two duodenal ulcer cases followed up endoscopically for longer than 3 years including 60 cases done for longer than 10 years were retrospectively analyzed for their endoscopic appearances. The results were the followings : 1) Both solitary ulcer and kissing ones had remained principally the same features in each during the follow-up period. There was no case that had developed into distinct linear ulcer after repeated relapse or recurrence in either type. 2) Linear ulcer cases in this study had already existed as linear ulcers from the initial endoscopic examination. Most of them had remained the same features through the follow-up peried. 3) In most cases of linear ulcers, the shape of the ridge had been unchanged during the follow-up period although the ridge had become flat or an ulcer scar on the ridge had become obscured in some cases of the linear ulcers. It must be aware that such cases were apt to be misdiagnosed endoscopically as either a solitary or kissing ulcer in such occa-sions.

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We have experienced 26 cases of drug-induced esophageal ulcer. Most of the 11 cases (under 70 years old) examined had underlying infectious diseases and had the onset of esophageal ulcer with chief complaint of pain (retrosternal pain, odynophagia or epigastric pain) within one day after taking antibiotics with small amount of water. In many of the 15 aged cases (over 70 years old), more than one underlying diseases and causative drugs were involved, and non-typical patterns of onset and clinical course were observed. The discontinuation of administration of causative drugs and anti-ulcer therapy were effective as the treatment, and the prognosis was good in many cases. However, some aged cases were led to death or delay of cure. As for the pathogenic mechanism, host factors are clarified, but drug factors largely remain obscure except for due to the high acidity, high osmotic pressure, ion concentration and heat of dissolution. To swallow the drugs down to the stomach with sufficient amount of water and not to lie immediately afterward are important for prevention of drug-induced esophageal ulcer. Also, as the disease may be caused by wide variety of drugs, strict direction and observa-tion are needed especially in the aged cases.

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Ten patients with rectal carcinoma who received ajuvant preoperative irradiation at a total dose of 42.6 Gy were followed endoscopically 6 times. The electoric endoscope (EPX-301 EVC-M 2) was employed to examine after receiving glycerin enema only. They were observed about the component of the tumor size. gross appearance, marginal elevation of the tumor, ulceration, easy bleeding and large intestinal diameter. Firstly, after 20Gy irradiation made the marginal elevation flat and 30Gy doses also replaced irregularity of the ulceration with smooth white coat. On 2 weeks after irradiation, the tumor size decreased and improvement of easy bleeding and dilatation of the istestinal lumen were recognized. On the basis of result of endoscopic observation, more than 30Gy irradiatin was necessary and edematous change of the tumor improved. Therefore, it was suggested that waitingtime of surgery was extremely important.

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Clinical studies were done in ten cases of intestinal Behcet's disease which were experienced at our clinic between 1978 and 1990. They consisted of 6 cases of incomplete type and 4 suspected cases. The age at onset ranged from 21 years to 51 years with a mean age of 35.8 years ; there were 6 males and 4 females. The main symptoms of Behcet's disease included oral aphthosis in all 10 cases, genital ulcers in 7 cases, skin symptoms in 6 cases so that these symptoms showed high appearance rates, but no ocular symptoms appeared. Among abdominal symptoms, abdominal pain was observed in the majority of 8 cases, melena in 3 cases, and diarrhea in 2 cases ; there was one case in which only discomfort in the abdomen, and chest pain as the main symptom were observed. The frequency classified according to affected region in the intestines was the enterocolon in 6 cases being the most common, the colon in 3 cases and the small intestine in 1 case. Lesion also appeared in the upper gastrointestinal tract including the pharynx in 3 cases, the esophagus in 1 case and the stomach in 1 case. Moreover, we report on two cases displaying interesting findings at the time of reccurrence. One case was observed with linear ulcer in the distal ileum and disappearing tendency of haustra in the ascending colon. Another case was observed with round ulcer in the ileocecal region and multiple red rings in the cecum.

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The clinical features and endoscopic findings were investigated in 17 patients with acute hemorrhagic rectal ulcer who were treated over a l0-year period. Acute hemorr-hagic rectal ulcer occurs with occasional passage of fresh blood in elderly subjects. There were 14 females and 3 males with a mean age of 71 years. Central nervous system disorders were associated in 9 cases, comprising cerebral infarction in 5, meningitis in 2, cerebral hemorrhage and myelopathy in one, respectively. Other associated disorders were fracture of the femur in two cases, acute myocardial infarction, diabetic rectovesical disorder, pyelonephritis and rheumatoid arthritis in one case, respectively. Malignant diseases associated with this condition were bile duct cancer accompanied by AOSC and colon cancer with liver metastasis in one case, respectively. The ulcers were geographic or nearly round in appearance, locating in the lower rectum, and multiple in many cases. In the base of the ulcers, exposed blood vessels were noted in 6 patients. Hemostasis was achieved by HS-E injection in 4 of these patients and by per anal ligation in 2. It is considered that when the associated disorder improves, the rectal ulcer heals rapidly.

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A 64-year-old female with slight odynophagia was referred to our clinic for further evaluation of malignant lymphoma of the esophagus. A tumor with a central ulceration was observed at the middle portion of esophagus and a Borrman 2-like lesion was also observed on the lesser curvature of the cardia by rentogenography and endoscopy. Although malignant lymphoma was highly suspected by routine pathohistological study on the biopsy specimen obtained from the esophageal and gastric lesions, no evidence showing lymphocyte origin was obtained with immunocytological and genetic analysis. Since Grimelius', Fontana-Masson and Keratin stainings of the biopsy specimens were negative and immunohistochemical staining for CEA was positive, the tumor was considered to be of epithelial origin. Consequently, the tumor was confirmed to be a primary anaplastic carcinoma of the esophagus with marked submucosal invasion and spreading of tumor cells into the lower portion of esophagus and stomach. Serum CEA levels were markedly increased from the 55th hospital day, and multiple metastatic lesion were found in both lobes of the liver by computed tomography. Since anaplastic carcinoma of the esophagus is considered to be very rare, a possible cellular origin and differential diagnosis of this cancer were discussed.

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We experienced a case showing an elevated scar at the healing stage of giant esophageal ulcer under proton pump inhibitor treatment. A 78-year-old woman was admitted, because of anterior chest pain. Endoscopic examination revealed a giant esophageal ulcer in the lower esophagus. Although she was treated with histamine H2-receptor antagonist, no improvement was noted. However, the ulcer showed remarkable improvement by the treatment with omeprazole ; a proton pump inhibitor. At the healing stage of the ulcer, an elevated lesion which was confirmed as a scar on histological examination was observed. After one month of treatment the scar became flat. Monitoring of esophageal pH for 24 hours revealed that the period showing pH less than 4 decreased significantly by the treatment with omeprazole. This is the first case presenting an elevated scar of esophageal ulcer.

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It is already known that pathological changes in the digestive tract, especially in the esophagus, are often noted in patients with progressive systemic sclerosis (PSS). We have examined the course of illness for aproximately 5 years of a patient who were repeatedly affected by esophagitis and esophageal ulcer, ending up in esophageal stenosis as described hereunder. The patient was a 41-years-old male who was diagnosed as PSS in 1981 on biopsy of his skin. Since 1985, his illness was complicated with esophagitis and esophageal ulcer which were gradually aggravated. H e visited to our hospital complaining of diffi-culties in swalloing from December 1989, and became almost unable to swallow down food since March 1990, and therefore, was hospitalized to our clinic. In january 1990, he had disturbances of myocardial transmission, and he had to undergo implantation of a pace maker due to its aggravation thereafter. Taking the possible presence of complication in his heart into consideration, we applied endoscopic esophageal dilatation ageinst the stenosis of the lower part of esophagus. His prognosis has been good to date both endoscopically and roentgenographically. It is rare that severe esophageal stenosis is brought about in cases with PSS, but there have been some cases reported of its surgical treatment. The dilatation method certainly have less incidences of adverse effects, but may tend to cause restenosis. When indication of the therapeutic methods against PSS should be made, it is suggested to take into consideration of the severity of disturbances of other organs.

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We resected endoscopically carcinoid tumors of the stomach in two patients by a method using strip biopsy. Histologic findings of the resected specimen in case 1, showed that the tumor was so-called classical carcinoid, which showed low potencial of malignancy. N o carcinoid cells were found both at the edge of resection and in the vessels of the specimen, being regarded as complete resection. There was no evidence of recurrence of the tumor post operatively as evaluated by endoscopy and also histology of biopsy speci-mens for 15 months. In another patient, the histology showed endocrine cell carcinoma. He was operated by subtotal gastrectomy because of high grade malignancy, although the tumor cells were not found in the edge of resection by endoscopic strip biopsy. There was no remaining carcinoma cells in the resected stomach, but the cells were found in the adjacent lymphnodes. These results indicate that the technique of strip biopsy was useful for diagnosis of carcinoid tumor of the stomach. The technique may be beneficial for treatment of classical carcinoid.

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A case of blue rubber bleb nevus syndrome (BRBNS) with complicating an early gastric cancer at the cardia was reported. A patient was a 74-year-old man complaining of swallowing difficulty. On admission, many hemangiomas, characterized by bluish rubber nipple like lesions, were recognized on the skin and in the oral cavity. There was no family history of the hemangioma and his parents were not consanguineous. Gastro-intestinal endoscopy revealed a diminutive protrusion with irregular erosion just below the esophago-gastric (E-G) junction, which was subsequently confirmed by biopsy as a well differentiated tubular adenocarcinoma. The simple total gastrectomy was carried out. During the operation, surgeons noted the presence of multiple hemangiomas on the liver, mesenterium, serosa of the small intestine, retroperitoneum and abdominal wall. The extirpated tumor was 13×12×4 mm in size, located close to E-G junction, and proved histologically to be well differentiated tubular adenocarcinoma which was limited to the submucosal layer. Also, histology of the intraperitoneal hemangiomas, resected from the mesenterium and liver tentatively, showed the enlarged and dilated vascular spaces separ-ated by fibrous tissue. The postoperative course was uneventful. By 1990, 47 cases of BRBNS have been reported in Japan. This is the first report of a case of BRBNS with complicating an early gastric cancer at the cardia, and receiving a total gastrectomy.

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A 63-year-old man was admitted to our hospital for further examination of anemia and reccurent gastric hemorrhage. Gastric endoscopy revealed scatterred red spots in the antrum which were easily bleeding. Diagnosis was histologically made as diffuse antral vascular ectasia. Since the ethanol injection therapy was not sufficiently effective, partial gastrectomy was performed. Histological examination of the removed stomach revealed two early cancers with 10mm and 5mm in diameters and they localized in the mucosa. The reason why no such malignant lesions was discovered preperatively was thought to be related with an intense redness of the vascular ectasias masking the presence of early cancerous lesions.

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Two cases of lymphangioma of the colon were clearly diagnosed by endoscopic ultrasonography (EUS). The 1st case, a 67-year-old male was admitted complaining of constipation and barium-enema examination and endoscopy revealed a soft submucosal tumor located at the ascending colon. As EUS showed multiple echo free spaces in the submucosa of the tumor and no abnormal findings were found by angiography, the tumor was finaly diagnosed as lymphangioma. Transendoscopic polypectomy was performed and histopathological examination revealed cavernous lymphangioma of the colon. The 2nd case, a 45-year-old woman was admitted into our hospital for the therapy of pyelonephritis. Extra-abdominal ultrasonography and CT scan showed polycystic lesion in the left flank. Barium-enema study and colon fiberscopy revealed a few cystic submucosal tumors at the descending colon. By EUS and angiography, a diagnosis of extramural and intramural lymphangioma of the descening colon was made. A cavernous lymphangioma was confirmed by histopathological examination of the resected colon.

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Using endoscopic strip biopsy, we treated one patient with superficial esophageal carcinoma and 3 patients with esophageal dysplasia. Resected specimens indicated that one lesion was intraepithelial carcinoma and three lesions were dysplasia. Two of them (one carcinoma and one dysplasia) were completely resected. We did not encounter any acute or late complications such as perforation or bleeding. It is concluded that strip biopsy was an effective method for the diagnosis and treatment of esophageal lesions.

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A newly developed bipolar polypectomy snare (Everest Medical) was used to remove 53 gastrointestinal polyps in 25 cases, and the results were compared with those obtained by a monopolar snare. Since the bipolar snare enables the current to pass from one section of the wire loop through the polyp to another section of the wire loop along the mucosa, the energy is confined to the outer layer, resulting in far less damage in the underlying tissue, compared with the monopolar snare. The bipolar snare for polypectomy has the following advantages: 1) there is little risk of perforation and it is possible to remove a big sessile polyp, 2) even in case that the tip of polyp touches the wall, polypectomy can be performed safely, 3) the polar plate is not necessary, 4) it is safely applicable to patients fitted with a pacemaker, and 5) with reduced tissue damage at the cut edge, it is beneficial for histological examination. Despite somewhat short durability, it is an ideal polypectomy system and seems to rapidly come into wide clinical use.

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