To clarify the relationship between Helicobacter pylori (H. P.) and gastric ulcer, H. P. infection and infiltration of inflammatory cells were investigated in 119 patients with gastric ulcer. Patients were divided into three groups, including 32 patients with intractable ulcers, 62 patients with recurrent ulcers, and 25 patients with initial ulcers. Biopsy specimens were obtained from both the ulcer and the background mucosa in these 119 patients and in 22 control subjects with normal endoscopic findings. The number of H. P. and the number of inflammatory cells were quantitatively determined using both HE staining and immunohistochemical staining for H. P.. H. P. was detected in 100% of the intractable ulcers, which was significantly higher than in the recurrent ulcers (82%), initial ulcers (68%), or normal gastric mucosa (59%). Furthermore, the number of H. P. in the patients with intractable ulcers (2, 240±400/mm²) was significantly higher than in those with recurrent ulcers (1, 850±490/mm²) or the normal controls (1, 150±550/mm²). Recurrent ulcers in both the gastric angle and the antrum showed significantly higher rates of H. P. infection than the gastric mucosa of normal controls. In the background mucosa, the number of neutrophils was significantly higher in patients with intractable or recurrent ulcers than in those with initial ulcers or the normal controls, and neutrophil numbers were significantly larger in patients with H. P.-positive gastric ulcers (232±32/mm²) than in those with H. P.-negative ulcers (44±17/mm²). In addition, a positive correlation was found between the number of H. P. and the number of neutrophils. Follow-up endoscopy revealed that the number of neutrophils at the ulcer margin decreased significantly over time in the patients with initial ulcers, but remained high in the patients with recurrent ulcers. These findings suggest that H. P. infection might result in the persistence and recurrence of gastric ulcer in association with gastric mucosal damage caused by neutrophils.

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Serum gastrin levels were measured before and after upper GI endoscopy in 178 patients, to clarify the influence of the endoscopy on serum gastrin levels. Serum gastrin levels after endoscopy elevated significantly by scopolamine butylbromide injection as a premedication, decreased significantly by glucagon injection and was not influenced significantly with no premidication. Gastric biopsy procedure was suggested not to influence on serum gastrin levels after endoscopy. Presence or absence of Helicobacter pylori was also suggested not to give significant changes in serum gastrin levels during endoscopy. In most cases, changes were within±30% of the level of pre-endoscopy, and the influence of premedication of butylscopolamine bromide were disappeared 30 minutes after endoscopy. Therefore, it was suggested that there was no practical problems to regard serum gastrin levels of after-endoscopy as the basal levels.

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Among the small lesions associated with ischemic colitis, we investigated transverse ulcer and scattered macular reddenings located on the anal side of the main lesion and the intervening normal tissue. No reports have so far described that transverse ulcer is characteristic of ischemic colitis. In this study, however, it was detected in 23% of the patients who could be examined endoscopically within a week after the attack. This fact raised the possibility that a diagnosis of mild ischemic colitis escaping detection of the conventional method may be made by endoscopic examination. The rate of detection of scattered macular reddenings located on the anal side of the main lesion was 24% of the patients who could be examined endoscopically within a week after the attack. When this lesion is recognized, it is suspected that a mild macular ischemic state exists scatterdly in a region separate from the main lesion. If ischemic colitis could be induced by vascular factors only, mucosal changes should develope in a limited area. The present study demonstrating separated lesions endoscopically in ischemic colitis suggests that some intestinal factors may play a role in the pathogenesis of this disease.

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In the study on the pathogenesis of liver diseases, measurement of the diameter of cirrhotic nodules is needed, and the usefulness of laparoscopic measurement is focused. In relation to this, development of a new method for measurement of the diameter of cirrhotic nodules in laparoscopic slides preserved is required. We calculated a diameter of cirrhotic nodules as follows ; distance of a specified site (mm)/number of cirrhotic nodules in a corresponding site counted in laparoscopic slides. As a result, almost the same values were obtained as those conventionally measured in use of a probe with a scale, when the standard is set to a length of the surface of left hepatic lobe. This method is, thus, considered to be useful. However, smaller values, about a half or less, were obtained, when the standard is set to a transverse length of the gallbladder. This method is thought to be unacceptable, because the gallbladder easily contracts and the transverse length is fluctuating.

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In anti-HCV positive chronic hepatitis, relationship of hepatitis C virus replication and peritoneoscopic findings of the liver has not been clarified. The purpose of the present study is to clarify correlation of distibution of hepatitis C virus and peritoneoscopic findings of the liver. Using in situ hybridization, HCV-RNA was clearly detected in the liver biopsy materials in patients with anti-HCV positive chronic hepatitis. The distribu-tion patteren was divided into four groups ; i, e. spotty, scattered, clustered and diffuse pattern. In the group of spotty pattern, peritoneoscopic examination revealed hepatic appearance of code number 200 in two third of the patients : However, in the group of clustered and diffuse patteren, most patients showed code number 400 and 500 of the liver under peritoneoscopy. Reddish marking and gutter-or-trench type depression of the liver were frequently observed in the group of clustered and diffuse pattern. From these observation, it is suggested that hepatitis C virus replication may play a role of progression of hepatic injury and may reflect peritoneoscopic findings of the liver.

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We tried endoscopic variceal ligation (EVL) by means of three-forked forceps and end-loop ligature. EVL technique is shown. First, we inserted three-forked forceps and end-loop ligature through 2 channel f iberscope. The varices was pulled to end-loop ligature by three-forked forceps, and was ligated. After the end-loop was closed and varices was ligated, the ligature was cut off with scissors forceps. We tried EVL for 10 esophageal varices, 6 gastric varices. As a result, esophageal and gastric varices were improved with healing of ulcer after EVL. A little amount of the sclerosant was necessary for complete elimination of esophagogastric varices. This method can decrease the side effect in the cause of the sclerosant. Further, it can ligate for huge gastric varices. We could conclude that this new method was useful modality for esophagogastric varices.

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The endoscopic findings and the association with Helicobacter pylori (HP) infection of the gastric mucosa, serum pepsinogen (PG) levels were examined in 99 patients with fundic gland polyp (FGP) and 139 with gastric cancer (GCA).1) Endoscopic findings showed no atrophic change in the folds of the greater curva-ture and antrum in the patients with FGP.2) 53 patients with FGP (53%) were associated with superficial gastritis (linear redness), but not gastric cancers, gastric adenomas, gastric ulcers and hyperplastic polyp.3) In the patients with FGP, serum PGII level was decreased. PGI/II ratio was remarkably higher as compared with in the GCA patients.4) Urease activity in the antral mucosa in the patient with FGP was negative. In 29 of 56 patients with GCA (52%) urease activity was also negative. Although serum HP antibody levels was normal in the patients with FGP, it was higher than normal in the patients with GCA. These results suggested that GCA patients have been infected with HP while FGP patients have not been infected. We concluded that the characteristic change of gastric mucosa of FGP patients is quite different from that of GCA patients and the presence of fundic gland polyp is a negative feature for gastric cancer.

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The problems in observation and insertion of peroral cholecystoscopy (POCCS) were investigated. Seven cases, five males and two females, underwent POCCS for gallbladder disease : cholecystolithiasis, 5 cases ; gallbladder carcinoma, 1 case ; and adenomyomatosis, 1 case. Age ranged from 41 to 78 years, and the average age being 64 years. Endoscopic sphyncterotomy had previously been performed in 6 cases suffering from choledocholithiasis to extract calculi. After insertion of the baby scope into the common bile duct through the mother scope, the ostium of the cystic duct was clearly visualized in 6 cases. The guidewire was straightly inserted into the gallbladder via the cystic duct as deeply as possible through the guidewire channel of the baby scope, and then the baby scope was inserted into the gallbladder along the guidewire. The baby scope could be inserted into the gallbladder in 5 cases. In two of these 5 cases, a catheter was needed to dilate the cystic duct or straighten the guidewire. On the other hand, it was impossible to insert the baby scope into the gallbladder in the remaining 2 cases. In one of them, although it was possible to insert the guidewire into the gallbladder, the 8-Fr dilation catheter could not be inserted into the gallbladder through the cystic duct because of severe bending at the distal portion of the cystic duct. In the other case, only the tip of the guidewire was inserted into the cystic duct, because it branched off at an abrupt angle. In five cases in which the insertion of the baby scope was successful, stones and adenomyomatosis could be observed. Furthemore, the findings characteristic of normal mucosa of the gallbladder, such as superficial small vessels and fine reticular patterns were visualized with close-up view. This suggests that POCCS would be useful in diagnosis of gallbladder mucosal diseases. However, the endoscopic image was not so clear due to insufficient light with more distant view.

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We performed transpapillary biliary sonography (TPBS) with a microscanner devel-oped by Aloka Co. Ltd., and the results of which are herein reported. The microscanner applied in this study was a mechanical radial scanner with a frequency of 20 MHz and a diameter of six Fr. Due to its small size, it was possible to insert it into the bile duct through the channel of a duodenoscope. The sixteen cases, consisting of six cases of choledocholithiasis treated by endoscopic sphincterotomy (EST), three cases of bile duct cancer, two cases of gallbladder cancer, one case of cholecystolithiasis, three cases of pancreatic cancer, and two cases of pancreatolithiasis, underwent TPBS. All the cases were treated with EST prior to TPBS. Insertion of the microscanner into the bile duct and recording of the ultrasonogram of the bile duct wall was achieved in all the 16 cases. The wall was demonstrated to be a two-layer structure fundamentally with a hypoechoic layer and a hyperechoic layer from the inside. The thickness of the hypoechoic layer and the total thickness as measured on the ultrasonogram was 0.4 to 0.9 mm (mean, 0.7) and 0.9 to 1.7 (mean, 1.4), respectively. The periampullary structure, including the muscle of Oddi and the proper muscle layer of the duodenum, was clearly demonstrated by TPBS. No significant complications occurred following this examination from the viewpoints of serum amylase level and subjective symptoms. It is expected that TPBS will provide much information, which is difficult to obtain with other modalities, on the wall of the bile duct and on the periampullary structure.

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A gastric cancer of ha type located in the cardia was resected with an endoscope which was inserted through a specially placed gastrostomy. The patient was a 80-year-old woman. Endoscopic findings showed a ha type gastric tumor at the cardia, and endoscopic biopsy revealed well differentiated adenocarcinoma. Because the patient have respiratory insufficency, a limited operation was desirable, but the lesion was located just beside the cardia and endoscopic mucosal resection (EMR) in the usual manner was thought to be technically impossible. Then percutanous endoscopic gastrostomy was performed with our original method by gastropexy, and an endoscope was inserted through the stoma. The elevated lesion beside the cardia was carefully observed frontally with the endoscope, and EMR was performed with the help of another endoscope which was orally inserted to lift up the lesion. This method enables us to perform EMR even if a lesion is located in the cardia.

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A 67-year-old woman was admitted to our hospital because of edema in the lower extremities in June, 1990. Cervical lymphadenopathy and marked lymphocytosis (leukocyte count of 20, 600/μl with 76.5% lymphoid cells) were noted. Endoscopic and radiologic examinations disclosed giant folds in the stomach, a cauliflower-like tumor in the ileocecal valve, and numerous polypoid lesions in the stomach, duodenum and entire ileum. The patient was diagnosed as having intermediate lymhoytic lymphoma with features of multiple lymphomatous polyposis of the gastrointestinal tract (MLP) on the basis of histologic and immunohistochemical examinations. The authors discussed by reviewing the literature whether MLP was a distinct clinicopathological entity or not.

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A 46-year-old man visited our hospital with a complaint of right upper eyelid tumor of soybean size. The tumor was resected and it's histological findings was suspicious of malignant lymphoma. Therefore, a systemic examination was performed to search the origin of the eyelid tumor. Barium enema and colonoscopic findings revealed multiple protruding submucosal tumors in the descending and transverse colon. They were about 25mm to 65mm indiameter. Histological findings of biopsy specimens taken from the tumor of the colon revealed malignant lymphoma, diffuse, small cell type. After the chemotherapy, the partial colectomy was performed. An immunohistochemical staining showed that the tumor of the colon consisted of MT-1 and UCHL-1 positive cells. But eyelid tumor did not show monoclonal proliferation of the lymphoid tissue. Consequently, this case was diagnosed as T cell malignant lymphoma of the colon. T cell lymphoma of the colon is very rare, and our case is the seventh report of this disease in Japan.

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A 59-year-old man, with no previous history and no family history, was admitted to our hospital because of diarrhea and hypogeusia. X-ray and endoscopic examination of the gastrointestinal tract showed numerous reddened sessile polyps. Histological examination of the biopsied specimens of the colon showed edematous cystic dilatation of the glands. Although ectodermal changes such as alopecia and onychotrophia were not found. This case was diagnosed as early stage of Cronkhite-Canada syndrome according to the endoscopic and histological findings. This case improved markedly with steroid therapy. Although the patient had been making satisfactory prognosis, colon cancer developed two years later. It is suggested that the therapy of Cronkhite-Canada syndrome in the early stage is important. Moreover the posibility is suggested that Cronkhite-Canada syndrome may be associated with colon cancer.

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A 47-year-old woman with the chief complaints of anemia and diarrhea was admitted. At endoscopic examination she was found to have multiple duodenal ulcerations with conspicuous converging folds ranging from the descending to the horizontal segment of the duodenum without stenosis. On the basis of bacteriological and biopsy findings, she was diagnosed to have tuberculosis accompanied by duodenal lesions. A review of the Japanese literature revealed the followings: 1) 70% of the reported cases of duodenal tuberculosis had marked duodenal stenosis, 2) as many as 83% of them had to undergo surgical treatment, and 3) the deagnostic accuracy of biopsy was only 35%. Our case was a rare one without evident stenosis that a correct diagnosis could be made by biopsy and well responded to medical treatment.

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Aortoenteric Fistula is a rare complication of aortic graft insertion surgery. A 75-year-old man was admitted with a complaint of melena 2 years after aortic graft insertion. Urgent upper GI endoscopy showed a cloudy mucosal lesion with erosions, edema and bleeding at the transverse part of the duodenum. Therefore, endoscopic clipping was performed and a gelatin solution was applied locally under diagnosis of Dieulafoy's ulcer. But aortogram and CT scan indicated that the clips used on the endoscopic hemostasis were in contact with the anterior wall of the graft. Therefore, a final diagnosis of secondary aortoduodenal fistula (ADF) was established, and an operation was performed. During surgery a fistula was found between the graft and the transverse part of the duodenum. Awareness of this entity is the first step toward a correct diagnosis. Patients who present with upper GI hemorrhage of any degree following aortic graft insertion should be examined by upper GI endoscopy as soon as possible under the suspicion of secondary ADF. Aortogram and CT scan after marking of the endoscopic clipping are also helpful in making a diagnosis of secondary ADF.

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A 50-year-old female visited Shinshu University Hospital in September 1990 with the complaint of diarrhea of approximately 10 months duration. The colonoscopic examination revealed multiple mucosal redness and remarkable mucous discharge in the sigmoid colon and rectum (Figure 1). However mucous existing among the lesions were nearly normal. Histological findings of biopsy specimens from the lesion showed atrophy and inflammatory cell infiltration in the surface of mucosa (Figure3). Culture of feces and serum anti-amoebic antibody were negative. Even with extensive examination, we were not able to classify this case into any hitherto known type of colitis. Alf a-one-antitrypsin clearance test showed that the progressive hypoproteinemia in this case was due to protein losing enteropathy. Metronidazole and oral administration of steroid hormone were not effective. The elementary diet and enema of steroid hormone improved her complaints and endoscopic findings temporarily (Figure 5), but frequent diarrhea recurred immediately after starting oral administration of diet. Surgical resection of sigmoid colon was performed because of resistance to conservative therapy. However, the colitis recurred after 2 months. Home alimentation wiht half digestive element and suppository of small dose of steroid hormone wef e employed continuously for 6 months, and diarrhea and hypoproteinemia were improved. Endoscopic examination showed multiple verrucous lesions, but mucosal redness and mucous discharge were disappeared (Figure 8).

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A 64-year-old female was referred to our institution for evaluation of positive fecal occult blood test. Barium enema and colonoscopy demonstrated an elevated lesion with clear demarcation and rough surface in the descending colon. Histologically, this tumor was made up by spindle cells with enlarged nuclei. The cells were arranged in a random or swirling fashion. In the immunohistochemical study, tumor cells were positive for S-100 protein and NSE stain. These findings suggested that this tumor was a Antoni type A Schwannoma. This was rare tumor of the colon (37 cases published up to 1993 in Japan).

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We have recently experienced a case of Lemmel's syndrome induced by meal rest in the parapapillary diverticulum. The patient was a 81-year-old woman admitted to our hospital with complaints of fever, right hypochondriac pain and jaundice. She had previously undergone the procedure of EST for common bile duct stones. Abdominal ultrasonography revealed the dilatated common bile duct. Endoscopic finding showed obstruction of the orifice of common bile duct by meal rest like plug. After endoscopic removal of meal rest, she was conservatively treated. As a result she was getting better.

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A 44-year-old man with chronic hepatitis C was examined by laparoscopy, which showed 3 whitish lesions of 1 to 2 mm in size on the anterior surface of the left liver lobe, and also a lesion of 2 mm in size on the anterior surface and a lesion of 5 mm in size at the edge of the right liver lobe. The 4 lesions of 1 to 2 mm in size were flat and well defined. The lesion of 5 mm in size had a mild rand-wall and looked like a plate. It showed neither central umbilication nor tumorous vessels. These whitish lesions are somewhat similar to laparoscopic findings of granulomatous liver diseases and cholangiocarcinoma. The punch biopsy specimen was diagnosed as bile duct adenoma, which was composed of small duct-like structures without cystic lumen and contained portal areas and lymphocyte infiltration. Some epitheliums were stained fine granularly with PAS and diastase-treated PAS. Luminal border of the epitheliums and mucin in the lumen were stained with alcian blue. Immunohistochemistry revealed that the ductular cells were positive in the cytoplasm for cytokeratin and CEA, and on their luminal border for CA19-9. The specimen biopsied from the liver parenchyma was diagnosed as chronic active hepatitis 2B. Bile duct adenomas have been found at laparotomy or at autopsy. But recognition of bile duct adenomas at laparoscopy would be expected because most of bile duct adenomas are located subcapsularly. So we should consider bile duct adenoma as one of differential diseases when whitish lesions were seen on the liver.

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A 74-year-old woman without a history of alchol drinking visited our hospital because of fever and abdominal pain. A mass in the head of the pancreas was detected by ultrasonography and abdominal computed tomography. ERCP showed shortening of the main pancreatic duct with cystic dilated branches and smoothh narrowing of the distal common bile duct. The dorsal duct, outlined by cannulation of the accessory papilla, was slightly dilated. We diagnosed this case as pancreas divisum with ventral pancreatitis. ERCP performed 21 days later showed that cystic dilatation of the branches of the ventral pancreatic duct and narrowing of the lower end of the common bile duct had improved. Communication between the two ductal systems was not demonstrated. About 10 years earlier, this patient complained of recurrent abdominal pain and fever. Since laboratory tests showed a raised serum amylase level, ERCP was performed at that time, and revealed malfusion of the pancreatic ducts (branch fusion type between ventral and dorsal pancreatic ducts). Incomplete pancreas divisum in this case became undistinguishable from pancreas divisum by ERCP following recurrent ventral pancreatitis. When discussing pancreas divisum, the presence of such a case should also be taken into consideration.

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A case of a 54-year-old women is reported with nonfunctioning islet cell carcinoma diagnosed preoperatively. She admitted to our hospital with abdominal tumor and icterus. Hypotonic duodenogram showed stenosis in the second part of the duodenum. US and CT revealed a mass, 8 cm in diameter, in the head of the pancreas. This case was diagnosed islet cell tumor preoperatively, due to biopsy of the exposed tumor in the second part of the duodenum. Pancreatoduodenectomy was performed. Histological diagnosis was nonfunctioning islet cell carcinoma. A Clinicopathological analysis of ever reported 5 cases of nonfunctioning islet cell tumor invading duodenum was also discussed.

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