We developed an improved type of EVC-HM which makes easily to observe the pit patterns of colorectal polypoid lesions at routine endoscopic examinations. Using the improved type of EVC-HM, we classified the pit patterns into 6 categories as follows : p0 : pit figure is round shaped and pit arrangement is regular p1: pit figure is star shaped and pit arrangement is regular p2 : pit figure is almost round or oval and its size is uneven, and pit arrangement is irregular p3: pit figure is tubular p4 : pit figure is sulcus or branching p5 : pit disapeared and only irregular surface is observedHistologically, type p0 or p1 is chronic inflammation or metaplastic polyps. Type p2 is widely ranged from chronic inflammation to tubular adenoma with moderate atypia. Type p3 is mainly tubular adenoma with mild or moderate atypia, and occasionally metaplastic polyp. Type p4 is tubular adenoma with moderate or severe atypia, and type p5 is carcinoma. The greater the number of pit pattern, the more atypical the lesion tended to be. From this classification of pit patterns, the rate of correct diagnosis whether the dimimutive lesion was neoplastic (adenoma or carcinoma) or not was approximately 90%. This rate was more excellent than from normal endoscopic observations. So improved type of EVC-HM was thought to be very useful at routine clinical works.

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The stenosis of the anastomotic site in upper gastrointestinal tract operations, which can develop soon after taking of food, is a serious condition not only for patients but also for surgeons. We have perf omed 470 procedures of stapling anastomosis between June in 1977 and December in 1991 in esophagojejunostomy and esophagoesophagostomy (esophgial transection). Stapling anastomosis can now be performed safely and speedily. In our earlier experience, anastomotic leakage was the most important complication of this procedure but the incidence of it has decreased drastically. Incidence of anastomotic stenoses, however, has increased. Since December in 1981, we have used a flat knife and a high-frequency cauterrization system for the anastomotic stenosis to improue such stenosis. Fifty-eight patients were treated by this method successfully. The method of incision and the endoscopic findings of postincisional conditions were evaluated analyzed. In our experience, stapling anastomosis with the SPTU produced stenosis most frequently and web-formation is the most common consative factor of the stenosis. The condition deveroped within three months in many cases. We believe that endoscopic incision is a very useful method in repairing anastomotic stenosis.

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We studied on 66 cases of gastric cancer, of which cases were treated by endoscopic YAG-laser irradiation or the heater-probe method. Especially, 8 of 66 cases which clearly showed protrusion of the lesion when compared with the state prior to the therapy, were investigated clinico-histopathology. Four of the 8 cases were carcinomatous protrusion histologically, and other were non-carcinomatous protrusion. Two cases of carcinomatous protrusion were underwent laser irradiation while the other were treated by the heater-probe method before the occurence of protrusion. Histopathological comparison between before and after the appearance of carcinomatous protrusion showed that increased structural atypia and cellular atypia in some cases. It suggested the possibility, the heat treatment such as laser or heater-probe might increased the atypical changes. Furthemore, the other cases showed marked cystic dilatation of cancer gland or granulation. It was also thought that they may have influenced tumor growth. Following treatment of car-cinomatous protrusion by endoscopy, no residual recurrence has been noted in early gastric cancer cases. From these findings, we considered that previous radical treatments were effective, if it was demonstrated as protruded type of local reccurence. Non-carcinomatous protrusion were noted in 4 cases, all of which received laser irradiation. Endoscopic differentiation between carcinomatous and non-carcinomatous protrusion was possible to a certain extent, by color and features of the suface.

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Relationship between non-ulcer dyspepsia (NUD) and Helicobacter pylori (HP) infection was studied in out-patients. One hundred six patients (NUD group ; 53 males, 53 females ; mean age, 50.0), complaing of upper-abdominal symptom (s) more than a month without any organic upper-gastrointestinal (GI) tract disease expect for gastritis proven by endoocopy, were registered. These patients were compared to an age, sex matched group of asymptomatic out-patients (N=81; control group ; 46 males, 35 females ; mean age, 51.9) without any organic disease in upper-GI tract by endsocopy. Patients in NUD group were divided according to the upper-GI tract symptom (s) into two groups as follows; 1) motility disorder (MD) group (N=41) of patients complaining of nausea, vomiting, or abdominal discomfort and 2) ulcer-like disorder (UD) group (N = 65) of patients with upper abdominal pain. No statistical differences were seen among MD, UD, and control groups in gastric juice pH, grades of gastric mucosal inflammation, or grades of intestinal metaplasia. The incidence of HP infection in MD, UD, and control groups was 41.5%, 26.2%, or 51.9%, respectively, and HP infection was significantly less frequent in UD group compared with the control group (P<0.01). Doses of smoking and alcohol consump-tion were significantly more in UD group than in MD or the control group. These results cast a doubt as to the causal role of HP infection for patients with NUD.

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Endoscopic variceal ligation (EVL) using elastic band (EVL-o) and clipping apparatus (EVL-c) have been reported as a new method of endoscopic variceal therapy. We tried EVL-c using HX-3L (Olympus Optical Co Ltd.) in 15 patients with esophageal varices and 12 of 15 patients were treated with the combination of EVL-c and endoscopic injection sclerotherapy (EIS) using 1 %polidocanol. As EVL-c technique was difficult to be performed safely, we used a transparent tip-hood attached forward-viewing f iberscope. Clip was completely covered with this hood when the clip stride range was maintained between 4.95 mm and 8.62 mm, and did not injure the esophageal varices. It was extremely important to detect the size of varices whether EVL-c was possible or not. First, EVL-c was performed at the site just above esophagogastric junction, and at the lower esophagus being 5-6cm above the first EVL-c point. Next, intravariceal injection of 1% polidocanol (2-3m1) was performed between two clips, and paravariceal injection of that (1.0-1.5 ml) performed at the site above esophagogastric junction. In this method, sclerosant could be retained in the varices for a long time, and total volume of sclerosant decreased remarkably. Twelve of 15 patients treated with this method were obtained an eradication of varices (F₁RC (-)). In 3 patients with hepatocellular carcinoma accompanied with main portal tumor thrombus, RC sign was not completely disappeared after therapy. Minor complications, such as fever, pleural effusion, and chest pain, decreased significantly. After this method, liver function was not worsened in any patient, though these patients had severe liver dysfunction. EVL-c + EIS method was expected to be a useful and safe therapy for esophageal varices.

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Colonoscopy was performed in 6455 patients over a period of 7 years and total colonoscopy was conducted in 2392 patients. Forty seven patients (M:F=44:3, Age 32.2×13.4) had ulcerous or erosive lesions on the ileocecal valve which were freqently observed in the following order: campylobacter colitis, unclassified erosion, crohn's dis-ease, infectious colitis (normal flore), ulcerative colitis, intestinal Behcet's disease, unclas-sified ulcer, salmonella colitis. We speculated that the endoscopic findings of infectious colitis differed from those of inflammatory bowel disease and the etiology of ulcerous and erosive lesions were due to high pressure on ileocecal valve. Unclassified ulcerous and erosive lesions were noted on screening colonoscopy. They were negative with fecal culture and laboratory findings, and had no diarrhea. The biopsy specimens showed nonspcific inflammatory features with fibroedema of stroma. We herein reported ulcerous and erosive lesions on the ileocecal valve, particularly interesting unclassified ulcerous or erosive lesions.

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We experienced choledochoscopy via the cystic duct during operation for cholecys-tolithiasis. In 15 of 19 patients with gallbladder stones, fiberscope could be inserted into the cystic duct to allow inspection of the intrahepatic and extrahepatic bile ducts. In 3 of the fifteen patients, common bile duct stones, which were not detected by the preoperative examinations and intraoperative choledochography, could be found by the fiberscopic examination. Our study showed that choledochoscopy via the cystic duct, by which direct observation of the inside of bile ducts is possible, can be a useful additional diagnostic method during cholelithiasis surgery.

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A 67-year-old woman came to our hospital because of epigastralgia and dysphagia. Endoscopic examination revealed that a vertical-striped white mass covered the entire surface of esophagus. Pathological examination revealed unusual spongiosis of the middle layer of esophageal squamous epithelium similar to the pathological change of the skin observed in pemphigus. As prior endoscopic examination of this patient had revealed no disease of the esophagus and because these symptoms had appeared in conjunction with the adminisrtation of mexiletine, we assumed this esophagitis was due to the drug and discotinued its administration. Symptoms disappeared promptly thereafter. Endoscopic examination one month later revealed almost normal esophageal mucosa. Most cases of drug-induced esophageal injury are produced by superficial ulceration and formation of an erythema of esophagus. There are only two reported cases of mexiletine induced eso-phagitis accompanied by ulcers confirmed by endoscopy. To our knowlege, this is the first report of esophagitis characterized by pathological findings of spongiosis and vertical-striped white mass confirmed by endoscpic examination.

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A 21-year-old man was transfered to our division because of massive hematemesis. He was to be agranulocytosis after two cycles of combination chemotherapy with Cisplatine, Etoposide and Bleomycin, and was also treated with bone marrow transplantation and G-CSF for mediastinal embryonal carcinoma. At the same time, he got fever and had chest pain. Some days after, he vomited blood. Emergency upper gastrointestinal endoscopy disclosed diffuse ulcers and active bleeding in the thoracic esophagus. Biopsy studies did not show any infections of candida, bacterium or virus. The ulcers healed up by conservative treatment. These diffuse ulcers may be due to immunodef iciency state or agranulocytosis origined after intensive chemotherapy. This paper presented a case of diffuse esophageal ulcers with agranulocytosis due to anticancer chemotherapy.

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A case of Strongyloides stercoralis infection associated with multiple stomal ulcers was reported. A 66-year-old male was admitted to our hospital because of dyspnea. Travel history included a military service in Burma during Wand WarII. A chest roentgenogram revealed emphysematous lung field. Dyspnea improved by corticosteroid therapy, but epigastral discomfort occurred. Endoscopic examination showed multiple stomal ulcers. Epigastric discomfort was improved by H₂-blocker. However, eosinopilia became remarkable. Stool examination revealed the rhabditiform larvae of Storongyloides stercoralis and biopsy specimens of duodenal mucosa demonstrated the proliferation of the larve with infiltration of eosinocytes to the mucosa. After administration of albendazole the larve in the stool diminished. He may be infested with the larve in Burma for the first time and corticosteroid therapy may aggravate the infestation. This patient should be followed up carefully for relapse of Strongyloidiasis.

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We used EHL, snare and mechanical lithtriptor (ML), whitch was used for stones in the common bile duct, to crush bezoar due to ingestion of "mamekaki" (berries of a japanese persimon) and stones came out from the anus, while the concurrent gastric ulcer was also treated. Case : 71-year-old female. Gastroscopy and gastric X-ray film revealed 2 gastric bezoar, 5.6×5.4×5.0 cm and 5.0×6.0×5.2 cm in size respectively, and stage A₂ gastric ulcer existed at the angulus. Gastric bezoars were removed using Olympus Lithotron EL21 and the one channel fiber-scope XK20. The bezoars were then divided by a snare, and fragmented to less than 2 cm with ML. Later, the crushed bezoars were found in feces. Gastric ulcer healed to S₁ stage in about 2 weeks after treatment. EHL seemed to have an advantage compared to a conventional snare or laser treatment, because it took only 45 min, and it could be used with a one-channel fiberscope, and was safe.

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A 64-year-old female with hypertension was admitted to the hospital for the further evaluation of cholelithiasis. Endoscopic findings on ERCP showed dark pigmentation resembling "black pepper", in appearance from the bulbus to the second portion of the duodenum. Light microscopic view revealed that the pigment resided in macrophages in the lamina propria of duodenal villi. Histochemically, the pigment was positive for Fontana-Masson stain, and bleached with permanganate and oxalic acid. Staining for iron by Berlin-blue was slightly positive. From these findings, a diagnosis of melanosis duodeni was made. Since the patient had taken antihypertensive drugs for a long time, we think that the pigmentation results from medications that contain a benzene ring. We also review the literature on melanosis duodeni in Japan.

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A 62-year-old man was admitted to our hospital because of bloody stool. Total colonoscopy had been done three times during one year and 4 months. Total thirty-three colonic polyps detected were polypectomized. Out of 33 polyps, 7 were mucosal carcinoma. On the third colonoscopy, a broad based elevated lesion, 1.0 cm in size, in the sigmoid colon which looked like submucosal tumor was also polypectomized. On histological study, it was shown to be well-differentiated adenocarcinoma which showed massive submucosal invasion and cancerous tissue at the cutting margin. Therefore, consecutive surgical resection of the sigmoid colon was performed. However, no local cancerous residue nor lymph node's metastasis were demonstrated. Early colonic cancer showing submucosal tumor is rare.

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A 21-year-old woman was admitted with complaints of vulvar pain, aphtha and fever, and was diagnosed as Behçet's disease, incomplete type. After admission, she complained of abdominal pain and anorexia. Therefore, gastrointestinal tract study was performed. Total colonoscopy revealed a well defined, round shaped ulcer (so-called 'punched out' ulcer) in the terminal ileum, and the diagnosis of intestinal Behçet was made. No ulcer was shown on other parts of digestive tract. At this time, we performed endoscopic mucosal biopsy of an erosion on the Bauhin's valve. After that, melena appeared. Colonoscopic reexamination after a week revealed a large 'punched out' shaped ulcer on the Bauhin's valve. With the medicine and nutritional therapies, intestinal ulcers healed. The mecha-nism of ulcer development in the intestinal Behçet has been still unknown. In this case, large ulcer was developed only a week after mucosal biopsy. This phenomenon is similar to the needle-response on the skin, and this case was considered to be a suggestive case.

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A 56-year-old woman with liver cirrhosis complained of tarry stool. She was admitted to our hospital for further examination. On upper endoscopic examination no esophageal or gastric varices and no ulceration were seen. There were no abnormal findings at X-ray series and endoscopy of small intestine. Barium enema showed round filling defect with slight irregularity, about 3cm of size located at the ascending colon. Colonoscopic exami-nation revealed submucosal lesion which color appeared slightly pale. Varices were suspected in addition to submucosal tumor. Color doppler ultrasonography and abdominal angiography demonstrated a enormous collateral vessel between superior mesenteric vein and inferior vena cava in right flank abdomen. Endoscopic ultrasonography revealed a luminal structure in the wall. corresponding to the elevated lesion, and we diagnosed colonic varices. Colonic varices are rare, but when patients with portal hypertension are examined, colonic varices must be took into account.

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An esophageal tube provided with a baloon cuff was evaluated. The outside diameter of the cuff can be adjusted by air injection. We used this cuffed tube for the treatment of malignant esophagotracheal fistula. A 65-year-old man with advanced esophageal cancer was admitted to our hospital. Esophagogram using gastrograf in revealed the presence of a esophago-tracheal fistula. After endoscopic intubation of the cuffed tube, he was able to swallow a soft diet for 35 days.The cuffed tube accomplished an adequate closure of the fistula.

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An assessment has been made comparatively regarding manipulativeness, safety and histological diagnosability of Automatic 18 Gauge Core Biopsy System (ASAP-18) made by Microvasive Co. developed in 1990 and 14G Tru-Cut Biopsy Needle (Tru-Cut) made by Baxter Co. in 20 cases on whom hepatic biopsy could be made concurrently. Sampling of tissue was possible by the use of ASAP-18 without helper, and its manipulation was simple, compared with Tur-Cut. The lengths of tissue piece were average 13.0 mm with Tru-Cut and average 14.1 mm with ASAP-18, being about the same. The numbers of Gllisson's capsule were average 16.4 with Tru-Cut and average 11.3 with ASAP-18, the latter being slightly smaller in number. Regarding histological diagnosability, difference was scarcely obseved with ASAP-18 in comparison with Tru-Cut in diffuse hepatic diseases, but the cases from whom no detailed findings were obtained included 33% of chronic hepatitic cases and 33% of cirrhotic cases. Hemorrhage after biopsy with ASAP-18 occured as that with Tru-Cut, but astriction with a probe was required in 1 case.

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