A 20MHz ultrasonic probe of the SONOPROBE SYSTEM using through the forceps channel of the usual endoscope has an excellent resolutionability and enables the simultane-ous sonoscanning and endoscopic observation. Although the application of this tool for the esophagus is not easy, because the usage of ultrasonic coupler such as water and the vertical ultrasonic incidence are difficult due to cardiac beats, breathing, and esophageal peristalsis. We devised an exclusive transparent overtube for SONOPROBE in clinical use, 74% of the scanning on the normal esophageal wall in vivo showed 9 to 11 sono-layers owing to exclusion of former problems. And intact esophageal wall was showed 9 to 13 layers (96% in 250 scannings) in vitro. The sono-layer originated from muscularis mucosa was confirmed by the study including the comparison between sono-layers and histologic pictures and experimental study with submucosal gelatin injection. Moreover, based on the analysis of ultrasonic pictures of superficial esophageal carcinomas, SONOPROBE SYSTEM could suggest the useful informations concerning to cancer invasion in lamina propria mucosae and muscularis mucosae.

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Esophageal mucosal tissue blood flow was measured using endoscopic laser doppler flowmetry in 12 cases of normal esophagus (control group), 6 cases of reflux esophagitis, 10 cases of advanced thoracic esophageal cancer and 5 cases of anastomotic benign stricture of cervical esophagus. Normal esophagus (control group) revealed good mucosal tissue blood flow more than 25 ml/min/100g, though the blood flow of upper part of esophagus was relatively lower than that of lower part of esophagus. Reflux esophagitis group showed the same blood flow as that of control group, and both advanced thoracic esophageal cancer group and anastomotic benign stricture of cervical esophagus group revealed significantly lower blood flow compared with the control group. The blood flow of advanced thoracic esophageal cancer seemed to change depending on the location, type of endscopic findings and depth of invasion of each cancer.

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To determine if patients undergoing regular hemodialysis (HD) have less gastric atrophy related with aging as compared with age-matched healthy subjects, we studied histological findings of the gastric mucosa endoscopically obtained from 6 standardized points (i. e., the lesser curvature of the antrum, angle, the lower body and upper body, and the greater curvature of the upper and middle body) in 39 patients undergoing regular hemodialysis and 31 age-matched healthy subjects. The width of the oxyntic gastric gland area was calculated by the formula of the histological scoring system [i. e., index of oxyntic gland area (IOGA)]. In addition, we studied correlations between TOGA and several clinical and biochemical parameters [i. e., serum levels of gastrin, parathyroid hormone (PTH) and calcium, patients' ages when studied, patients' ages when HD was initiated, durations of HD]. We found that patients undergoing regular HD had wider oxyntic gland areas than age-matched healthy subjects, and more than half of HD patients had cobble-stone appearance on the oxyntic mucosa, being compatible with so-called endoscopically hypertrophic gastric mucosa. Because oxyntic gland area is known to become small by aging, it was suggested that HD patients may have younger stomach for their age. We also found that there were significant (p<0.05 or 0.01) negative correlations between IOGA and the serum gastrin level, patients' current age and patients' ages when HD was initiated. However, no significant correlations were observed between IOGA and the duration of HD, serum levels of PTH and calcium in our HD patients. In conclusion, these data suggested that patients undergoing regular HD may have wider oxyntic gland areas for their ages, and that hypergastrinemia frequently observed in HD patients was not likely to be a causal factor of the HD-related histological alternation in the gastric mucosa (i. e., younger stomach). Further studies are required to determine if other endogenous trophic factors (e. g., epidermal growth factor, pancreatic glucagon, cholecystokinin-pancreozymin) and causal factors of chronic atrophic gastritis (e. g., Helicobacter pylori, bile salt) might be contributing to the gastric mucosal alternation related with HD described as above.

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We made a prospective study of colonic vascular ectasia (VE) in patients who were going to undergo endoscopic examination of the colon, excluding those with liver cirrhosis. Our findings were summarized, as follows: 1) Out of the 430 cases examined during a period of 2 years and 4 months, VE was detected in 13 cases (3.0%). 2) The patients with VE ranged in age from 30 to 91 years, with a mean of 71 years, which was significantly higher than those (54 years) of the other patients. 3) VE was often located in the right colon, commonly occurring as a solitary lesion. 4) Chronic heart failure and cerebral infarction were found with significantly higher frequency in the VE group than in the age and sex matched control group. 5) Endoscopically, most lesions were flat, but some were inhomogenous in structure and irregular in border. 6) Bleeding was observed in only 2 cases and asymptomatic cases accounted for 85% of the total cases studied. However, in the light of the high incidence of VE, the proportion of hemorrhagic cases may increase in fututre in Japan as in the U. S. A. and European countries.

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Four cases with melanosis duodeni were described. Two cases were associated with chronic renal failure, and one case with hypertension. The other case is a deaf 23-year-old woman suffering from psychogenic vomiting and constipation. The duodenal mucosa of these cases, on endoscopy, showed scattered black or brown flecks, extending from the bulb to the proximal second portion of the duodenum. The density of the color faded away gradually at the distal portion of the papilla Vater. Through a magnifying fiberscope, the stroma and the tip of the villi appeared to be pigmented. On electron microscopy, the size and shape of pigmented granules were variable in individual case. The electron-probe x-ray analysis showed that these pigments contained f errum and/or sulphur. These ultrastructual findings reveal that the constituents of pigment differ in each case of melanosis duodeni.

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1) Follow-up examination after endoscopic polypectomy of the colon and rectum has been made in 376 cases. The detection rate of new lesions was 39.4% (new adenoma 36.9 %, new cancer 2.4%). 2) The new lesions were milder in histological grade of atypia, smaller in size and located more proximal sites than those of the initial lesions. 3) The factors increasing the incidence of the development of the new lesions were more than two polyps, severe atypia, larger size, pedunculated shape in initial lesions and older male patients. 4) The detection rate of the new cancers was increased in the following three groups of initial lesions. (1) adenoma of severe atypia or carcinoma on histology (2) larger than 20mm in diameter (3) patients older than 70 5) The prognosis of the patients in this study was excellent. There were no death. We recommend that the patients who received endoscopic polypectomy of the colon and rectum are advised to have the examination of the colon and rectum every 2-3 years for long period.

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Results of Endoscopic Pancreatic Biopsy (EPB) for the diagnosis of early pancreatic carcinomas were reported. Pancreatograms of cases of pancreatic carcinomas were classified to subtypes and analyzed to evaluate the usefulness of EPB. Cancerous materials were obtained in 65% in obstruction group and 79% in stenosis group. Overall positive rate was 71% (38 of 54 cases). New type of biopsy forceps were developed and studied for the efficacy to obtain cancerous tissues. To increase positive rate of EPB, use of appropriate type of biopsy forceps was essential as well as visualizing precise pancreatograms. ERP provided to be most useful in early detection of pancreatic carcinomas among various diagnostic modalities.Results suggested that:(1) use of ERP as screening method(2) demonstration of precise pancreatogram, and (3) accurate sampling by biopsy were important in the early diagnosis of pancreatic carcinomas.

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In order to elucidate the difference of liver surface between anti-HCV positive and negative alcoholic liver diseases, laparoscopic findings of 23 HCV positive cases and 84 negative cases were investigated. In the HCV positive group, small depressions, dotted whitish markings, reddish markings, large and small mixed nodules and capsular turbidity were dominant. On the other hand, in the HCV negative group, checkered whitish marking, exposure of the right lower surface and yellowish brown color were dominant. Therefore, the differentiation of both groups was thought to be possible. However, among the positive group, the cases in which both laparoscopic and histologic diagnoses were inconsistent were noteworthy especially in the laparoscopic diagnosis as alcoholic liver fibrosis. In the 23 HCV positive cases, eight cases (35%) were histologically diagnosed as micronodular cirrhosis or alcoholic liver fibrosis in which alcohol might play a major main role in the liver disease. Thus, laparoscopy waas supposed to be useful to define whether the liver disease was due to alcohol or virus even in the anti-HCV positive patients.

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We clinically applied endoscopic microwave tissue coagulation therapy (EMT) for treatment of bleeding after colonoscopic polypectomy. In three cases with pulsatile bleeding and seven cases with oozy bleeding, a round type electrode was placed on the bleeding point of a cut surface of the stalk, and microwave was then discharged at the level of 50 watt for 5 to 10 sec. The hemostatic effect was satisfactory without any complica-tions. When the electric coagulation seemed inadequate, we also applied EMT for the prevention of hemorrahage after colonoscopic polypectomy. With EMT, we have no experience of severe hemorrhage. The hemostatic effect of pure ethanol injection on bleeding after colonoscopic polypectomy is not always satisfactory. Recurrent bleeding sometimes occurs, bacause of the inadequate injection into a cut surface of the stalk. However, a round type electrode can be easily applied to a cut surface of the stalk, and a satisfactory hemostatic effect can be obtained using EMT. EMT is a very effective method that can be easily and safely used for the treatment and prevention of hemorrhage after colonoscopic polypectomy.

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A 41 year-old, male with dystrophic epidermolysis bullosa complained of anemia and admitted to our hospital. Upper gastrointestinal examinations demonstrated the circular stenosis with a liner ulcer and erosions at the upper esophagus. Two weeks later of the first endoscopy, the endoscopic examination was performed and a hematoma was revealed at the point of the previous biopsy and some erosions, which were perhaps developed occurred by the contact of the fiber, were shown at his pharynx. Stenosis or complete occulation of the esophagus are potentially life-threatening complications of dystrophic epidermolysis bullosa, because of poor nutrition or malignant tumors which occurred from esophageal ulcer scars. So we consider that endoscopic examination of the upper gastrointestinal tract for patients with this disease should be done very carefully.

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A 52-year-old man was referred to our hospital with the diagnosis of gastric polyp.Endoscopic examination revealed a submucosal tumor with shallow central depression on the anterior wall of the antrum. Thereafter, the tumor was followed up endoscopically and found no change of size for two years. Then endoscopic resection was tried with no success, so the superficial mucosa of the tumor was cauterized. Three days later most of the tumor was dropped out with ulceration. Two months later a tumor with erosion on the top appeared and gradually increased. One year later the tumor became twice the size of the original tumor. Then the tumor was resected surgically and diagnosed as inflammatory fibroid polyp histologically. The growth of the tumor was supposed to be accelerated by ulceration.

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A 58-year-old female was admitted to our hospital complaining of epigastric distress. Gastrofiberscopy revealed a submucosal tumor on the anterior wall of upper gastric body which had become larger within 2 years. Endoscopic ultrasonography showed that a heterogeneous hypoechoic tumor originatred from the muscularis propria directly invaded the liver. Operation was performed. The tumor with a central ulcer, 23×23×10mm in size, invaded directly the hepatic left lobe. Disseminated metastasis to the omentum and other peritoneum was observed. The histopathological diagnosis was malignant leiomyoblas-toma, though mitotic counts were none. We reported here the smallest malignant gastric leiomyoblastoma in Japan, which was strongly suggested to be malignant by endoscopic ultrasonography.

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We have experienced two cases of malpositioned duodenal papilla associated with morphological abnormal duodenum. Case 1: A 48-year-old man visited complaining of tarry stool. Emergency endoscopic examination of the upper gastrointestinal tract revealed bleeding from gastric ulcer. On the examination, there was a small elevated lesion with elliptic redness about 1 cm distal to the pyloric ring. This was found to be a duodenal papilla confirmed by ERCP. Twice gastrointestinal fluoloscopies showed that the descending portion of the duodenum was shifted from left to right from its normal position, This suggested the mobile duodenum. Case 2: A 71-year-old man was referred for the investigation of anemia and leg edema. Emergency endoscopic examination of the upper gastrointestinal tract showed hyperplastic atrophic gastritis and easily bleeding portion at the antrum. ERCP revealed that the duodenal papilla was located close to the pylorus as same as case 1. Gastrointesti-nal fluoroscopy showed marked cystic dilatation of the terminal portion of the descending duodenum which was consistent with megaduodenum. These two malpositioned duodenal papillae in anormalous duodenum were detected at the time of endoscopic examination for upper gastrointestinal hemorrhage. Many cases of duodenal anomalies were reported in the literature. However, no cases with malposition of the duodenal papilla have been reported. In patients with duodenal anomalies, we have keep in mind of the anomalous location of the doudenal papilla.

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We have experienced two cases of malpositioned duodenal papilla associated with morphological abnormal duodenum. Case 1: A 48-year-old man visited complaining of tarry stool. Emergency endoscopic examination of the upper gastrointestinal tract revealed bleeding from gastric ulcer. On the examination, there was a small elevated lesion with elliptic redness about 1 cm distal to the pyloric ring. This was found to be a duodenal papilla confirmed by ERCP. Twice gastrointestinal fluoloscopies showed that the descending portion of the duodenum was shifted from left to right from its normal position, This suggested the mobile duodenum. Case 2: A 71-year-old man was referred for the investigation of anemia and leg edema. Emergency endoscopic examination of the upper gastrointestinal tract showed hyperplastic atrophic gastritis and easily bleeding portion at the antrum. ERCP revealed that the duodenal papilla was located close to the pylorus as same as case 1. Gastrointesti-nal fluoroscopy showed marked cystic dilatation of the terminal portion of the descending duodenum which was consistent with megaduodenum. These two malpositioned duodenal papillae in anormalous duodenum were detected at the time of endoscopic examination for upper gastrointestinal hemorrhage. Many cases of duodenal anomalies were reported in the literature. However, no cases with malposition of the duodenal papilla have been reported. In patients with duodenal anomalies, we have keep in mind of the anomalous location of the doudenal papilla.

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A 68-year-old man visited to our hospital after abnormality of the stomach was pointed out by gastric mass survey. Endoscopy disclosed a slightly irregular ulcer with thick whitish exudation at the lesser curvature (a little to the posterior wall side) of the middle gastric body. The biopsy specimen was Group II. He was treated with H2-blocker and cytoprotective agents. One month later, the ulcerative lesion was cicatrized. The endoscopy performed another 6 months later revealed that the lesion had changed into a protruding lesion with uneven surface and slight whitish exudation. The biopsy specimen was Group V, tub 1. Then the previous biopsy specimen was re-evaluated, and revised as Group IV. In the resected specimens, the protruding lesion was type III of Yamada's classification and a shallow depression was present in the surrounding mucosa of the fundus region, showing type I+IIc like lesion. Histologically the protruding lesion consist-ed of papillary adenocarcinoma. The cancer cells in stem lesion inveded into submucosal layer and of the shallow depressed lesion into mucosal layer. This case, which was transformed from depressed type to protruding type in a short period of 7 months, is extremely rare. And this is considered to be an important case with special reference to the influence of H2-blocker.

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A 57-year-old male with appendiceal-sigmoid fistula was reported. The patient had no symptoms related to the gastrointestinal tract with exception of transient bowel habit disorder. Barium enema examination revealed a fistula from the sigmoid colon to the appendix. Colonofiberscopic examination demonstrated an inlet of the fistula covered with a mucosal bridge and diverticula in the sigmoid colon. Histologic examination of the resected specimen (appendix and bowel wall) showed only mild inflammatory change. Appendicitis was suspected but the definite diagnosis was not obtained. An appendiceal-sigmoid fistula with mucosal bridge was discussed with a review of the literature.

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A case of intraperitoneal hemorrhage caused by rupture of pancreatic pseudocyst is presented in this report. A 50-year-old male was admitted to our hospital with a chief complaint of upper abdominal pain. Laboratory data on admission revealed anemia. Ultrasonography revealed two cystic masses in the body of the pancreas and the left upper abdomen. Abdominal CT suggested the bleeding into a pancreatic pseudocyst and to peritoneal cavity. To determine the souce of hemorrhage, celiac angiography was performed, but an extravasation of the contrast medium was not shown. The inflow of contrast medium from the pancrearic duct into the cyst was shown on ERCP. The patient was treated conservatively and then, on the 18th day after admission, distal pancreatectomy was performed. The clots were macroscopically confirmed in the pancreatic pseudocyst and peritoneal cavity. Postoperative recovery was uneventful and the patient is well 2ldays after surgery.

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A 27-year-old woman was admitted to our hospital for massive melena after intensive medical therapy (TPN, SASP 3g/day and oral prednisolone 40mg/day) in another hospital. The patient remained in severely active state of ulcerative colitis (total colitis type) both symptomatically and endoscopically on admission. Coombs' test was positive with both direct and indirect methods, and she had IgG type of anti-red blood cell antibody. Steroid pulse therapy was employed, starting on 4th hospital day. In brief, 3 courses of intravenous administration of 1g/day of hydrocortisone for 3days were given. Immediately after pulse therapy, clinical symptoms and signs were improved, and endoscopic findings showed improvement to the 2nd stage of Matts' grading. Interestingly enough, anti-red blood cell antibody was diminished during pulse therapy associated with decreased activity of ulcerative colitis. Association of anti-red blood cell antibody in ulcerative colitis patients, though rare, was discussed in addition to efficacy of steroid pulse therapy.

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A 54-year-old female was admitted to our hospital because of hematemesis and jaundice. On the endoscopic examination, a giant irregular elevated lesion accompanied with ulceration was found in the duodenal bulb. Histological examination revealed non-Hodgkin's lymphoma (diffuse medium cell type). Computed tomography showed the thickening wall of duodenal bulb, and which invaded the pancreatic head and the liver (7 cm in diameter). Complete obstruction was found at the level of common hepatic duct by percutaneous transhepatic cholangiography. Garium scintigraphy revealed the accumula-tion at the same area. The tumor was disappeared by chemotherapy (COP-BLAM) and irradiation (30Gy). She has no recurence for 22 months. Primary malignant lymphoma in the duodenum is rare. Only 28 cases have been reported-in Japan, in which there have been only 6 cases (including our case) diagnosed without or before operation. There were a few cases which the tumor were disappeared without resection.

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Gianturco type expandable metallic stent (EMS, Z stent) was successfully inserted through the duodenal papilla for the internal shunt formation in 2 cases of unresectable malignant biliary stricture. Case 1 was a patient with malignant tumor originating in the gallbladder. Z stents were inserted and shunt patency had been kept for 60 days until the patient's death because of the advancement of original malignancy. Case 2 was a patient with malignant tumor locating at the hepatic hilus. Z stent with overcoated Dacron-fabric was inserted and its patency was kept for 90 days to date. EMS was known to provide the larger internal diameter, if compared with the previous type of tubes and Z stent provided the multiple merits. However, Z stent insertion via the duodenal papilla has never been reported. We consider that the method of endoscopic internal shunting will be further applied as the treatment of choice, as shown in our successfully controlled cases.

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