To investigate seasonal fluctuations of peptic ulcer disease, monthly occurrences of endoscopically diagnosed active gastric ulcers (601 cases) and duodenal ulcers (289 cases) were examined. When dividing the months of the year into four consecutive three-month periods, there were 171 cases of gastric ulcers from March to May, 164 cases from June to August, 139 cases from September to November and 127 cases from December to February (p<0.05). Duodenal ulcers occurred in 63 cases from January to March, 68 cases from April to June, 61 cases from July to September, and most fequently from October to December with 97 cases (p<0.05). Thus, seasonal fluctuatons of peptic ulcer disease were observed in the Nagoya City district, and gastric ulcers frequently occurred in spring and duodenal ulcers in autumn to early winter.

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Forty-seven cases with early gastric cancer (adenocarcinoma) in the cardia were divided into two groups, 17 cases with the center of cancer at less than 1 cm from the esophagogastric junction (EGJ) (Group I) and 30 cases with the center of cancer at 1 to 2 cm from EGJ (Group II) and clinicopathological characteristics and endoscopic findings between the two groups were compared. Clinicopathological caracteristics: The characteristics common in the two groups were high prevalence in elderly males; predominance of differentiated type; high incidence in the lesser curvature and posterior wall; higt incidence of concurrent lesions in the stomach; and general progression of cancer in the mucosa toward the shorter axis of the stomach in a blet. Differences between the two groups were predominance of elevated type in Group I and depressed type in Group II; high sm rate (53%) and a tendency toward sm invasion when the size exceeded 1 cm regardless of macroscopic findings in Group I; high esophageal invasion rate in Group I as expected and high incidence of concurrent ulcers in Group II. Endoscopic findings: There was no difference in those two groups the color of depressed type cancer was usually red in both Groups I and II regardless of the depth of invasion. Some parts of lesions were associated with hemorrhage and white coat. The surface was usually smooth in most cases.

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The images obtained by electronic endoscope can be expressed by numerical values. We attempted to differentiate the stages of ulcerative colitis numerically by computer analysis of the images obtained by a magnifying electronic colonoscope, type CF-200HM. The subjects were 95 cases with ulcerative colitis and 18 normal subjects. After spraying of methylene blue on the mucosa, magnifying colonoscopy was performed. Red component was extracted from the images, scale transformation was exerted, and then binalization images were made. The ratio of non-staining area (area of gland orifice) in concerned area was calculated. As a result, the values correlated with the staging determined by symptoms, endoscopy and histology. Our approach was considered to be useful for quantitative assessment of the stages of ulcerative colitis.

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Endoscopy with fluorescence had been attempted during the period of fiberscope, however, the change on endoscopic image was insignificant and the objective analysis of the sequential changes was impossible. We tried to quantitate the change of electronic colonoscopic image after administration of fluorescent material by computer analysis. The subjects induced 5 cases with colorectal cancer, 6 with adenoma, 7 with ulcerative colitis and 7 controls. Electronic endoscopic images were sequentially recorded as digital data every second for two minutes after intravenous administration of fluorescent material. Each image was processed by computer to accentuate the change with fluorescence. The results showed that the duration until the appearance of fluorescence was the shortest in control, followed by the quiescent phase of ulcerative colitis, active phase in ulcerative colitis, adenoma and cancer. Endoscopy with fluorescence is expected to be applied for the differential daignosis of colorectal tumors and the staging of ulcerative colitis.

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There are various technical difficulties in insertion of endoscope and cannulation into the papilla in patients who underwent Billroth II operation. The insertion to the papilla is easier with a forward-view type, but it has some disadvantages such as a shorter effective length and difficulty in obtaining a frontal view of the papilla. ERCP and EST were attempted using a forward-view type endoscope with a device of transparent hood attached to its tip in order to overcome those difficulties mentioned above. This device enabled not only easier insertion of the endoscope to the papilla by shortening the redundant intestinal loop but also visualization of its frontal view. Consequently, the cannulation into the papilla was easily done by sucking the papilla into the tip of the attached hood as compared to the cannulation using the front-view type endoscope without the transparent hood device.

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Strecker-stent implantation was performed in 12 patients with obstructive jaundice ; 6 bile duct cancers, 3 pancreatic cancers, 2 gallbladder cancers and 1 residual gastric cancer. The numbers of transhepatic approach and transduodenal approach were 10 and 2, respectively and then, these patients had been followed-up for 3 to 43 weeks. Although obstructive Jaundice did not recur in 43 weeks in one patient, in one-third of all subjects jaundice recurred within several weeks after Strecker-stent implantation. Autopsies revealed that jaundice was caused by cancerous infiltration to the duodenal papilla in a patient with gallbladder cancer or by neoplastic proliferation across the mesh of Strecker-stent in 2 patients with bile duct cancer. With regard to the stent patency period, it remains difficult to make a comparison between Strecker-stent to conventional stents in view of insufficient length of observation. The fact that one-third of subjects had re-obstruction within several weeks after Streckerstent implantation suggests the need for investigation of subject selection and stent length, stent improvement and considerations of multi disciplinary treatment.

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We have developed a new type of fine fiberscope (2.2 mm in external diameter) for peroral transpapillary observation of the bile duct or the pancreatic duct without papillotomy. This scope consists of a image glass fiber with 3000 pixels, seven light-guide plastic fibers and one working channel of 1.0 mm in diameter. The scope can be inserted into the bile duct or the pancreatic duct through the channel of the conventional duodenoscope. Another devices of this kind of fine scope, which have already been offered for clinical use, are very fragile. The fragility makes it difficult to use it for clinical practice. When we planned to revise this fine scope, we paid our attention mainly to reduce fragility. Exchanging the light guide glass fibers for plastic fibers was the most important progress on that point. Insertion of the scope into the bile duct or the pancreatic duct through the conventional duodenoscope requires no special techniques. Another amelioration concerned to the shape of the tip and location of the working channel of this scope must be brought out in order to perform easy insertion into the bile and pancreatic duct through normal papilla, because the success rate of insertion of the present scope is not high (60%). Direct inspection by the fine scope will improve the diagnostic reliability for lesions of the bile duct and the pancreatic duct.

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A 60-years-old female was admitted to our hospital for the diagnosis of a gastric polyp. Endoscopic examination revealed a submucosal tumor on the lesser curvature of the antrum. Endoscopic ultrasonography showed homogeneous hypoechoic mass in the 2nd to the 3rd layer of the gastric wall. This tumor was resected endoscopically, and diagnosed as "Inflammatory Fibroid Polyp".

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A case of eosinophilic gastroenteritis with gastric ulcer showing a mass-like protrusion due to marked granulomatous proliferation is reported. A 17-year-old male with a complaint of pain in the epigastrium was admitted to our hospital for further evaluation of gastric ulcer on the lesser curvature of the antrum. Endoscopic examination revealed a gastric ulcer with mass-like protrusion accompanied by redness and erosion in the surrounding mucosa. Marked eosinophilia, iron deficiency anemia and hypoproteinemia were found. Biopsy specimen from the protruded gastric ulcer as well as antral and duodenal mucosa showed diffuse eosinophilic infiltration. The diagnosis of eosinophilic gastroenteritis was made with laboratory and endoscopic findings including biopsy. It was considered that steroid therapy combined with anti-ulcer drug was useful for the gastric ulcer lesion from the clinical course.

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We have experienced three cases of massive bleeding from intestinal anastomosis. Case 1 was a 42-year-old male who visited our hospital because of melena. He had undergone side to side ileocolostomy 30 years ago. Without clinical diagnosis, an urgent operation (end to end ileocolostomy) was performed. The mucosa of pouch showed hemorrhagic erosions. Case 2 was a 70-year-old male who had melena. He had undergone side to side ileoileostomy 10 years ago. RI examination showed prompt radionuclide uptake in the small intestine. Superior mesenteric angiogram revealed a focal area of extravasation of contrast medium in the small intestine. On laparotomy, ulceration in the side to side ileoileostomy was demonstrated. Case 3 was a 75-year-old female with melena. She had undergone side to end ileocolostomy 57 years ago. Colonoscopic examination demonstrated ulceration in the side to side ileocolostomy. Postoperative ulcer following side to side anastomosis is a rare complication. We studied characteristics of ulcer in side to side anastomosis and reviewed 35 cases reported in Japan.

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A 55-year-old male was admitted to our hospital for excision of a polyp in the duodenum on September 7th, 1990. He had no remarkable symptoms or findings on physical or laboratory examinations. A pedunculated polyp with normal mucosa was found by endoscopy in the second portion of the duodenum, and a superficial cancer of the middle esophagus was also detected. The duodenal polyp resected under endoscopy was diagnosed as a carcinoid-ganglioneuroma by histological examination. Esophageal carcinoma was resected by the radical operation. Case reports concerning intestinal ganglioneuroma are extremely rare. We reviewed 12 cases reported in Japan. Five of them were treated with endoscopic polypectomy. Although ganglioneuroma is benign disease, this case will require the follow-up examination because of the coexistence of carcinoid.

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Von Recklinghausen's disease (VRD) is characterized by café au lait spots and multiple skin tumors. It may also be accompanied by other systemic lesions. We report a case of leiomyosarcoma of the jejunum associated with VRD and observed by endoscopic examina-tion with a review of the literature. The case was a 63-year-old female who was admitted to our hospital with the complaint of cold sweat. On physical examination, there were café au lait spots and cutaneous neurofibromas over her entire body which revealed VRD. Laboratory findings indicated severe anemia. There was no remarkable abnormality in the stomach, duodenum or colon. X-ray examination of the small intestine and superior mesenteric angiography suggested a myogenic tumor of the proximal jejunum. Endoscopic examination using duodenofiberscope (OLYMPUS JF-B3) revealed a sessile submucosal tumor with an ulcer on the top. Surgical exploration revealed one semipedunculated tumor extending extraluminally at the proximal jejunum and twelve small raised nodules in the serosa of the same portion. Partial enterectomy was performed. Histologically the tumors were diagnosed as leiomyosarcoma. She is well without any recurrent signs for two years after the operation.

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A 32-year-old female visited our hospital because of diarrhea. On barium enema, mucosal granular change and luminal narrowing were found from the rectum to caecum. Colonoscopic examination showed erosions and ulcers from the rectum to transverse colon with luminal narrowing of the sigmoid colon. Mucosal biopsy revealed amyloid deposition. The patient was diagnosed as having primary amyloidosis because the amyloid deposit was histologically resistant to potassium permanganate and was successfully treated with DMSO therapy.

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A 71-year-old man suffering from chronic impairment of pulmonary function was found to have liver dysfunction suggestive of impending obstructive jaundice. Ultrasono-gram and endoscopic retrograde cholangiography disclosed an irregular tumor (2.0×2.0cm) in the distal end of the dilated bile duct. Endoscopic papillotomy demonstrated the obstructing mass arising from the pancreatic side mucosa of ampulla. Histological study of biopsy specimens from this tumor revealed well-differentiated tubular adenocarcinoma. Subsequent series of 4 segmental snare excisions must have enabled to remove the tumor completely. The patient's postoperative course of the biliary outflow was uneventful. Laboratory and endoscopic examinations had been normal over the following 2 years until he died of pulmonary failure. Therefore, this report suggests that endoscopic surgery is an acceptable treatment to excise the carcinoma involving the ampulla of Vater unless the lesion has poor prognostic features such as ulcerative or widely invasive.

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A case of duodenal mucosal bridge was reported. This is a rare condition and to our knowledge, only 5 cases including ours have been reported so far in Japan. We have recently experienced a case of duodenal mucosal bridge. The patient is a 93-year-old female without any complaint. There were no abnormal findings on physical examination. Laboratory data did not show other abnormal findings except for slight elevation of erythrocyte sedimentation rate. Endoscopic examination showed an arch-like mucosal bridge in the duodenal bulb. Double contrast x-rays picture of the duodenal bulb showed an arch-like radiolucency in the same region. Histopathological findings of biopsy specimen taken from the mucosal bridge revealed hyperplasia of Brunner's gland, but did not reveal fibrotic changes.

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Two cases of inverted colonic diverticulum (ICD) are reported. Case 1 was a 60-year-old male who underwent further examination of the colon because of an increased level of 3.9 ng/ml CEA. Colonography showed an elevated lesion with central depression in the mid-transverse colon. On colonoscopy the lesion appeared to be IIa+IIc-like. However, a diagnosis of ICD was confirmed since the shape was altered with time and the elevation disappeared. Case 2 was a 66-year-old male, who underwent colonoscopy because of positive fecal occult blood testing. Colonoscopy showed a polypoid lesion in the distal ascending colon. The lesion changed in shape with time under endoscopic observation. In addition, palpation using dye-spraying forceps showed dimpling sign, and the lesion finally everted to a diverticulum. A total of sixteen cases of ICD, including the present cases, was reported from 1979 to 1992 in the world literature. ICD is important in the differential diagnosis of colonic elevated lesions.

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The separated orifices of the common bile duct (CBD) and main pancreatic duct (MPD) is rarely encountered, and reported to be lower than 4% in Japan. We conducted endo-scopic sphincterotomy (EST) in 2 such cases : the one with common bile duct stone (case 1), and the other with benign sphincter stenosis complicated after cholecystectomy (case 2). No complication was seen, and the post-EST course was uneventful in both cases. The differentiation from choledochoduodenal fistula is required for the diagnosis of the separated openings of CBD and MPD because the incision range is basically different in both conditions. The direction of incision is oriented toward the proximal side from the orifice of CBD in case of the separated openings while the incision is made up from the main orifice of the papilla to the edge of its orifice in case of choledochoduodenal fistula.

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A 57-year-old woman with mitral valvular disease was admitted to Tenri hospital because of dyspea on exersion. On the following day after admission she complained of epigastralgia. Ultrasonography showed marked dilataion of common bile duct. Although cholangiogram couldn't be obtained by ERCP because of periampullary diverticulum, an elevated lesion like submucosal tumor was seen on the anterior wall of the antrum of the stomach. Histological examination of biopsy specimen from the tumor revealed adenocarcinoma. At operation the patient was diagnosed as cancer of the gallbladder which invaded the stomach. Cholecystectomy, partial gastrectomy and resection of choledocal cyst were performed. Intraoperative cholangiography revealed the spindle-shaped dilatation of common bile duct and anomaly of the pancreaticobiliary union. This is a rare case of gallbladder carcinoma associated with congenital bile duct dilatation, which was found by its gastric involvement.

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In a patient with non-dilated type anomalous connection of the pancreaticobiliary ducts (ACPBD), we were able to observe the lumens of common channel, bile duct and pancreatic duct by POPS. The patient was a 31-year-old woman with a chief complaint of epigastric pain. Ultrasonography revealed gallstones and gallbladder wall thickening. Drip infusion cholangiography disclosed spindle-shaped dilatation which is often found in case of ACPBD at the terminal portion of the bile duct. The patient was admitted to our hospital because of a suspicion of ACPBD. Endoscopic ultrasonography and endoscopic retrograde cholangio-pancreatography allowed a diagnosis of non-dilated type ACPBD. She was accompanied by gallstones and gallbladder adenomyomatosis, too. PCPS showed the opening of a pancreatic duct branch on the wall of a common channel. It also visualized cholesterosis in the bile duct and no abnormal findings in the pancreatic duct. PCPS was found to be useful in diagnosing minute lesions in case of ACPBD.

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Using a new instrument named video microscope, we observed resected stomach by magnifying the mucosal surface. Foveolar or sulciolar patterns were found under ×50 magnification. However, under ×200 magnification, we observed changing of the sulciolar pattern because of appearance of new pit-like lesions. The new pit-like lesions were found to be equivalent to interstitial parts in the mucosal layer. We think that this new instrument is useful in many medical fields because of the higher magnification than stereomicroscope.

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We developed a new method of endoscopic mucosal resection using a cap-fitted panendoscope for the treatment of early gastric cancer, which is called EMRC. The cancer -bearing mucosa is packed inside a specially devised plastic cap under full endoscopic suction, followed by snare cauterization. Four early gastric cancer cases received this novel procedure and were successfully treated by repeated cauterization. The specimen taken was about 2cm in size at the first cauterization and well contributed to histopath-ological analysis. Using this method lesions in any part can be treated safely and easily. The resected specimens can be easily retrieved. We have never encountered any major complications such as mass bleeding or perforation. We believe that this novel procedure is useful and effective for endoscopic resection of early-stage gastric cancer.

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After endoshopic sphincterotomy (EST), gallstones were extracted from the bile ducts of two elderly patients with implanted pacemakers using a wire basket. One was a 76-year -old female requiring a pacemaker for a complete atrioventricular block and her complaint was abdominal pain due to choledocholithiasis. The other was a 93-year-old female given a pacemaker due to sick sinus syndrome and her complaint was also abdominal pain with jaundice due to choledocholithiasis. Since EST by means of diathermy current has been regarded as contraindicated for pacemaker patients, reports of such a treatment are few. However, in the present cases, careful performance of EST and cooperation with cardiologists brought about successful results. Application of endoscopic treatments using diathermy current for pacemaker patients therefore deserves further consideration, offering the possibility of non-surgical intervention in difficult cases.

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