Endoscopic ultrasonography (EUS) was performed in 14 patients with cancer of the papilla of Vater by the balloon contact method with filling water in the duodenum. EUS pictures of the tumors were investigated. And the diagnosis by EUS for their expansion to the duodenal wall and pancreas and metastasis to the lymph node were compared with histological findings. Moreover, detection rates of the tumors by EUS were compared with those of US, CT, ERCP and angiography. And accuracy rates of EUS for malignant spread were compared with those of ERCP and angiography. From above investigations, cancers of papilla of Vater were generally presented by EUS as heterogenious, low echoic tumors with irregular margin and EUS was thought to be the very useful procedures in the diagnosis of the extension of the cancer of papilla of Vater.

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Vessels in the submucosal layer of gastric wall were able to be observed with infrared ray electronic endoscope. We evaluated the extent of gastric cancer infiltration (especially submucosal layer) using infrared ray electronic endoscope. Twenty three patients with advanced gastric cancer were examined with both conventional and infrared ray electronic endoscopes at the same time. We wedged some clipps at the border of cancerous infiltration where mucosal surface was intact under visible light but submucosal vessels were interrupted under infrared ray. We performed microangiography in resected stomach and identified the vessels observed under infrared ray. As the result, we confirmed the extent of cancer infiltration histologically. We classified 4 types histologically for the type of invasion : mucosal spreading, massive submucosal invasion, slight submucasal invasion and expansive invasion. The findings with infrared ray were classified into 4 types : obscured type, stoppping type, tapering type and unclassified type. Endoscopic findings of mucosal spreading with infrared ray revealed obscured type and tapering type, those of massive submucosal invasion, stopping type and unclassified, those of slight submucosal invasion, tapering type mainly and obscured type and those of expansive invasion, obscured type. It is concluded that infrared ray electronic endoscope can provide additional information of the submucosal layer and is useful for determining the extent of gastric cancer.

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Usefulness of double stent endoscopic retrograde biliary drainage ERBD was reported in the management of inoperable biliary diseases, where two ERBD tubes were inserted into the left and right intrahepatic bile ducts. Compared with the single stent group treated with conventional ERBD, drainage worked significantly long in the double stent group ; 50% of duration maintaining an effective drainage was 96 and 163 days, respectively (p< 0.01). Double stent ERBD showed, however, no significant effect on the survival period of the patients compared with single stent ERBD (Kaplan-Meier's method). Although it has been difficult to insert two ERBD stents into the malignant hepatic hilar strictures, the use of a Radif ocus Guidewire and skill enabled us to complete the procedure in many cases. Double stent ERBD could improve quality of life of the patients through extending a drainage area and prolonging duration maintaining an effective drainage.

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We attempted to differentiate depressed type of gastric adenoma from depressed type of gastric carcinoma endoscopically. The material consisted of 14 depressed type adenomas, 7 depressed type carcinomas in adenomas and 41 intramucosal carcinomas (IIc type, well differentiated type). Endoscopic feature of depressed type adenoma was slight redness with the unclear demarcation surrounded by relatively rough and large nodules. The base of the depressed area was flat, and the marginal slope was gentle. Most important endoscopic f indisngs of gastric carcinoma were : (1) vivid redness or Slough in the lesion, (2) large and small nodules and/or flat structure in the base of depressed area, which could be demonstrated by dye scattering method. However, the complete discrimination between adenoma and carcinoma was difficult through endoscopic examination.

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Two cases of gastric submucosal tumor and one case of esophageal submucosal tumor, which were resected via endoscopy are reported. In all cases, endoscopic ultrasonography was capable of visualizing that the tumor was located in, but not beyond, the submucosal layer, indicating that endoscopic resection of the tumor was safe. Pathological examination after removal led to the diagnosis of "aberrant pancreas" in case 1, "Inflammatory fibroid polyp" in case 2 and "leiomyoma" in case 3. We emphasize that endoscopic ultrasonography can pic up good candidates for endoscopic resection of submucosal tumors of the upper gastrointestinal tract.

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We made a clinico-pathological study of 18 resected cases of low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) of the stomach with special reference to the macroscopic findings. The 18 patients were 8 men and 10 women with the average age of 53 years. In 11 patients, the chief complaint was abdominal pain. Seven patients had histories of gastric ulcer. Endoscopic diagnoses were malignant lymphoma in 4 patients, early gastric cancer in 7 patients, multiple gastric ulcers in 3 patients and gastritis in 4 patients. The first endoscopic biopsy showed MALT lymphoma in only 8 patients but the final biopsy showed MALT lymphoma in all patients. The macroscopic findings were classified into 2 types. One is gastritis type in 8 patients, and the other is early gastric cancer-like type in 10 patients. In all patients with the former type, the depth of invasion was limited to the submucosa. In the latter type, it was limited to the mucosa in one patient, the submucosa in 8 patients and the proper muscle in one patient. In each type, 3 patients had lymph node metastases. In the former type, endoscopic findings were irregular cobble stone mucosa with superficial multiple erosions or ulcers, friable atrophic gastritis-like mucosa and discolored mucosa. In the latter type, endoscopic findings were early gastric cancer (type IIc, IIc+III and IIa+IIc) like findings and multiple gastric ulcers with cobble stone mucosa. For the purpose of diagnosing MALT lymphoma, it is important to bear the existence of the gastritis type of MALT lymphoma in mind and perform endoscopic biopsy. Total gastrectomy is recommended as the best treatment of this entity because the whole stomach was involved by lymphoma cells in 11 of 18 patients and macroscopic identification of the exact extent of a lesion was very difficult.

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We investigated the relationship between the endoscopic findings and clinical features in 31 cases of acute hemorrhagic rectal ulcer (AHRU), including 5 cases of rectal exposed vessels without obvious ulcerations. Irregular-shaped ulcers were found in 6 of 13 patients with cerebrovascular diseases. Round-shaped ulcers were seen in 4 of 5 patients with liver disorder and in all of 4 patients after laparotomy. In 5 of 7 patients with renal failure, ulcers were observed on the anterior wall of the lower rectum. However, many cases did not show the difinite relationship between the endoscopical findings and backgrounds of patients. In conclusion, AHRU should be regarded as a syndrome caused by various factors. Close examination on endoscopical findings and backgrounds of each patient is necessary to clarify the pathogenesis of AHRU.

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Seventy patients with cancer of the colon or rectum were endoscopically or surgically treated at our clinic during the three years from January, 1988 to December, 1990 and 45 of them could be followed up until December, 1992. Adenomas were developed in 23 patients (51%). In addition, chronologically different tumors which were all early cancers were developed in five patients (11%). These five cases had been operated on for advanced cancer and the time from surgery to tumor regrowth ranged from 19 to 29.5 months with an average of 25.7 months. These findings seem to stress the importance of the following posttreatment follow up program: 1) An advanced cancer case in whom the proximal colon of the lesion could not be examined preoperatively should be subjected to the first endoscopic examination a half year after treatment. The first examinaton can be postponed till a year after surgery in case the preoperative examination of whole colon was possible. The subsequent follow up colonoscopy to the third examination should be done at one year's intervals. Thereafter, follow up colonoscopy should be carried out every second year. 2) The first examination should be performed on an early cancer case one year after treatment and all subsequent examinations should be done at two years'intervals.

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24-hour continuous measurement of intragastric pH has been widely used in the evaluation of peptic ulcer treatment, but few fundamental works have been done on this practice. The work present here was performed to document problems of 24 hour continuous measurement of intragastric pH and its significance by comparing this test with gastrin stimulated acid secretion test and investigating pH variation between gastric body and antrum. In gastric body, a transient increase of pH (pH≥4) was observed after meals and pH4 holding time was same as in antrum. But pH in gastric body was not affected by spike-like change of pH encountered in antrum induced by the reflux of duodenal juice. The pH4 holding time in gastric body tended to correlate negatively with maximal acid output and to be different in various gastropathies diagnosed by endoscopic examination. In conclusion, pH in gastric body may reflect intragastric pH without influence of the meals and gastro-duodenal ref lux.

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The usefulness of endoscopic ultrasonography (EUS) in the diagnosis of cystic lesion of the pancreas was evaluated. EUS was carried out in 24 cases (6 patients with pseudocysts, 2 patients with retention cysts, 9 patients with mutinous cystadenomas, 4 patients with mutinous cystadenocarcinomas and 3 patients with serous cystadenomas) with cystic lesion of pancreas which had been confirmed histologically after surgery. The image of pancreatic cysts by EUS was shown clearer than that by conventional US. The image of cystic wall and internal structure by EUS was almost consistent with their pathological findings. The image of the pancreatic cysts by EUS was classified into four based upon whether or not a septum and a protrusion existed : Ia type (monocluster without protrusion), Ib type (monocluster with protrusion), ha type (multiclusters without protru-sion), and IIb type (multiclusters with protrusion). The cyst, including a septum and/or a protrusion, was found in EUS findings, and diagnosed as Ib, ha, IIb type of neoplastic cyst mentioned above. In this case, the accuracy of diagnosis reached an extremely high rate of 92%. Besides, noteworthy is the fact that, taken the properties of wall and the sizes into consideration. The efficiency of the diagnosis of pancreatic cystic disease is expected to be improved remarkably in quality.

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A case of dermatomyositis with mucosal bridge in the esophagus was reported. A 46-year-old male developed muscle weakness of the extermities. He was admitted to our department and treated with predonisolone and ciclosporin under a diagnosis of der-matomyositis. Four days after beginning of the treatment he developed abdominal discomfort accompanied by nausea and vomiting. Endoscopy revealed punched-out ulcers probably due to drugs were demonstrated in both esopagus and stomach. Three weeks later, mucosal bridge which occurred as healing restoration process of the ulcer was found across the esophageal ulcer at the middle esophagus. Another mucosal bridge was also found at the lower esophagus in the third endoscopy performed 9 months later. In addition to case report, we reviewed briefly 57 cases of esophageal mucosal bridge reported in Japan.

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A 45 years old male with a chief complaint of epigastralgia was admitted to our hospital for further examination. Endoscopic examination revealed three irregular depres-sions surrounded by multiple cystic lesions. Histological diagunosis of biopsy specimens obtained from these depressive lesions were group V. Cystic lesions of Yamada's type I were covered with nomal gastric mucosa, and could be easily depressed by biopsy forceps. EUS revealed multiple hypoechoic masses in the 3rd layer of gastric wall. A diagunosis of submucosal heterotopia of gastric glands was made by these findings. Distal gastrectomy was performed. Histological examination of the resected specimen confirmed three lesions of early gastric cancers, moderately differentiated tubular adenocarcinomas. Submucosal heterotopia was localized in the so-called F line and its anal side. Histologically they consisted of retension cystlike glands in the superficial layer of submucosa. Smooth muscle fibers around them linked the muscularis mucosa. In addition, we could find retension cysts of gastric glands in the tunica mucosa, invasion of gastric glands to muscularis mucosa, thinness and breakdown of musclaris mucosa, and atrophic or meta-plastic change of superficial mucosa. Based on these findings, we suppose that chronic inflammation may induce submucosal heterotopia of gastric glands.

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A 26-year-old woman visited to our hospital with a complaint of epigastralgia at hungar. Routine upper X-ray examination showed conglomeratic folds and bridging folds in the angle and the antrum. Endoscopic examination also showed mucosal bridges and ulcer scars. These mucosal bridges were considered to occured by the traffic accidnt, 8 year ago. Many cases of mucosal bridge in inflammatory bowel disease were reported, but gastric mucosal bridge is rare. Only 13 cases with gastric mucosal bridge have been reported in Japan.

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A patient was 20-years-old male who was admitted to our department on December 20, 1990 with the chief complaint of abdominal fullness, anorexia and ascites. The examination on admission revealed hypoproteinemia, hypoalbuminemia and fluid retention in the abdominal and thoraciccavities. Biopsy specimens of the duodenal and colonic mucosa disclosed demonstrated showed the dilatation of lymphaticduct. Level of α₁-Antitrypsin in the stool increased and 99m_Tc-Alb scintigraphy (RI angiography) revealed intestinal accumulation. Baced on the elevation in anti-nuclear and anti-DNAantibodies and a positive reaction of lupus anticoaglant, a diagnosis of protein-losing gastroenteropathy with suspicion of systemic lupus erythematosus (SLE) was made. This patient showed a remarkable response to steroid therapy.

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A 69-year-old male noticed melena 1990. Although this symptom persisted, he left it untreated. In July 1991, the patient noticed weight loss in addition to melena. Abdominal ultrasonography and CT revealed a mass in the right colic flexure as well as intraperitoneal lymphnode swelling. Colonoscopy disclosed a large mass in the right colic flexure and diffuse nodular polyps throughout the large intestine. Histopathological examination showed a non Hodgkin's, diffuse, mediumsized cell type. Although the morphological features of the gastrointestinal lesions in this patient were identical with those of multiple lymphomatous polyposis of the gastrointestinal tract (MLP), swelling of intraperitoneal lymphnodes could not rule out the possibility of systemic malignant lymphoma. Considering these features of this case and the fact that the previously reported cases of MLP included some cases with MLP like lymphoma, it seems necessary to review the definition of MLP.

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A 25-year-old Japanese female, who had undergone total colectomy with ileorectal anastomosis for ulcerative colitis 14 years ago, was admitted to our hospital for treatment of nodule-aggregating lesion in the rectal stump. As some of the biopsy specimens showed severe dysplasia, the rectal mucosectomy and ileo-anal anastomosis were performed. Well differentiated adenocarcinoma localized in mucosal layer was observed in the operative specimen.

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A 61-year-old male was admitted for examing multiple low density areas in the liver on computed tomography (CT). His body weight was 81kg, which was (measured) more than 30% overweight. Laboratory data on admission showed mild elevation of transaminase and diabetes mellitus. Abdominal ultrasonography and CT showed multiple space occupying lesions, which diameter were 0.2-0.6 cm in size. Laparoscopic findings revealed the liver cirrhosis, which color of nodules was yellowish. Liver biopsy specimen showed pseudolobules with or without marked fatty infiltration. Diet therapy was performed to reduce body weight and resulted in disappearance of multiple space occupying lesions. Thus, this is a very rare and interesting case with multiple focal fatty infiltration.

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A 76-year-old female was admitted to our hospital complaining of jaundice. US and CT revealed dilatation of the whole biliary tree, a large solid mass in the extrahepatic bile duct and a solid mass suggestive of lymph node swelling, 3 cm in diameter, located behind the lower bile duct. PTC showed a large tumor, 7×3 cm in size, occupying the inner space from the top to the middle of the dilated extrahepatic bile duct and a solitary filling defect in the lower bile duct, 11×4 mm in size, which moved with changes in position. Repeated cytology of bile collected from a PTBD tube were negative. The bile duct tumor possessed a whitish surface and was diagnosed as a poorly differentiated adenocarcinoma on biopsy at PTCS. A cholangioscope could be inserted into the lower end of the bile duct beyond the tumor, so the solitary filling defect could be confirmed as a gallstone. The bile duct tumor was hypervascular and supplied by cystic and inferior pancreatic duodenal arteries. From these findings, a diagnosis of bile duct carcinoma with gallstone and lymph node metastasis was made. Bile duct resection and lymph node dissection were carried out. Macroscopically, the bile duct tumor was found to adhere slightly to the wall, growing to fill the bile duct like a ′cast′. This case is of interest because it is rare that intrabile duct papillary carcinomas showed poorly differentiated adenocarcinoma on histology.

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A 66-year-old female was admitted because of loss of weight, 6kg in two months. US, CT and MRI revealed the enlargement of the pancreas tail and multiple irregular cystic lesions. ERCP showed no pancreatogram, pancreas divisum was suspected and the cannulation was carried out into the accessory minor papilla. The findings of dorsal pancreatogram were irregular dilatation from head to tail portion with multiple filling defects and pooling of contrast medium in the tail of the pancreas. She died after six months from the admission, and was diagnosed as solid and cystic tumor of the pancreas by the autopsy.

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Recently Press-Through-Pack (PTP) has become a popular package of medicine, and reports of accidental ingestion of PTP have increased. We have experienced three cases of esophageal PTP-foreign body. Sharp edges of PTP easily damage the esophageal wall so that a careful manipulation is necessary at endoscopic extraction. In all these cases, PTPs were removed safely using sliding tube for sclerosing therapy of esophageal varices using endoscopy. Sufficiently dilated esophageal wall by sliding tube gave the favorable visual field, and sliding tube could easily collect PTP-foreign bodies. We think that endoscopical removal of foreign body which applied slit type-ST should be tried in perforated esophageal cases due to the accidental ingestion of PTP.

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Seven hundred fifty five cases of mucosal carcinoma of the esophagus collected from 113 institutions by questionaire were analysed. Of those, 299 cases were epithelial carcinomas (ep carcinoma) and 456 cases were invasive carcinomas limited within the muscularis mucosa (mm carcinoma). The endoscopic features suggested that the superficial protruded type (0-ha) and/or the superficial elevated type (0-I) may have the risk of vessel invasion, lymph node metastasis or recurrence. No cases of ep carcinoma had vessel invasion, lymph node metastasis and recurrence. However, cases of mm carcinoma had vessel invasion and/or lymph node metastasis in 12.3% and recurrence in 4.2%. Almost all cases were operated on curative surgical reconstruction without removal of cervical lymph nodes. Most common recurrence occurred with cervical lymph node metastasis. Death with original disease occurred in no cases of ep carcinoma and in 13.8% of cases of mm carcinoma. The incidence of postsurgical death was 8.2% in ep carcinomas and 10.3% in mm carcinomas. A postoperative 5-year survival rate in cases of mucosal (ep and mm) carcinoma except cases died postoperatively and of other causes was lower in cases with vessel invasion and/or lymph node metastasis than in cases without them (p <0.001). The overall 5-year survival rates were 80.3% in ep carcinoma and 76.1% in mm carcinoma, respectively. Since nearly 20% of mucosal carcinomas died within 5 years of surgery, much safer method of treatment for mucosal carcinoma of the esophagus should be established in the near future.

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The lumen of the gut is separated form the internal milieu by an intestinal barrier comprising epithelial cells connected by tight junctions. The barrier inhibits passage of HRP (horse raddish peroxidase) and other tracer molecules. This lecture deals with following problems concerning the intestinal barrier and substance transfer through it. 1. For a short period after birth, substances are pinocytosed by the epithelial cells of the small intes-tine and conveyed to the internal milieu. 2. Coarse substances, even bacteria and viruses, may be taken up and transferred by M cells on Peyer's patches. 3. The intestinal barrier has been suspected to be broken at the tip of intestinal villi where effete epith-elial cells are exfoliated. We recently demonstrated in the guinea pig that the apoptotic epithelial cells are, only in their basal, principal portion, lysed and phagocytosed by large granular lymphocytes (LGLs) and macrophages, while their apical portion remains at the site. During the process of this cell apex being pinched off by pressure of surrounding cells, the tight junctions are preserved by the latter cells (Iwanaga et al. 1992, Han et al. 1993). Thus, in the guinea pig, likely also in the monkey and in humans, the intesti-nal barrier is not broken due to epithelial cell death.

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Clinical investigation of gastritis made a great progress with developments of gastric endoscopy and biopsy procedures. These investigation defined classification of gastritis as shown by Schindler, Tazaka -Sakita and Kimura-Takemoto. In this lecture, I have focussed clinical aspects and pathophysiology of 4 gastric lesions such as acute gastric mucosal lesions, gastric erosion, Kammrotung and portal hypertensive gastropathy.1) acute gastric mucosal lesions: Histopathological study of these lesions showed ischemic changes similar to those of ischemic colitis and organ reflection spectroscopy through a endoscope showed a decrease in tissue O₂ saturation. Luminol dependent chemiluminescence analysis revealed marked generation of free radicals. 2) gastric erosions : Gastric mucosa showed no changes in tissue Hb contents and O₂ saturation measured by organ reflection spectroscopy. Luminol dependent chemiluminescence of biopsy specimens was significantly increased. 3) Kammrotung : These lesions appeared on the fundic gland without any atrophy. Organ reflection spectroscopy showed an increase in tissue Hb contents without any changes of O₂ saturation. However, there was no change in free radical generation. Ratio of total cross section area of blood vessels against gastric lamina proprial area in Kammrotung mucosa markedly increased compared with that in controls. 4) Portal hypertensive gastropathy : organ reflection spectroscopy showed a significant decrease in tissue O₂ saturation without any Hb contents. Ratio of total cross section area of blood vessels 2lgainst gastric mucosa area in these lesions was markedly increased compared with that in controls. 5) mucosal inflammatory cytokines : Semiquantitative analysis of mucosal cytokines such as IL-1, IL-6, IL-8 and TNF-α showed marked expression of these mRNA except IL-6 by using RT-PCR method. Summary : Since stomach is always irritated by inner and outer agents, gastritis is thought as a continuously changing spectrum showing disturbed microcirculation and altered expression of mRNA in gastric mucosa.

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[in Japanese]

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