We studied the morphological changes of advanced gastric cancer in 10 cases responding to systemic chemotherapy. Endoscopic findings including the characteristics of ulcer base and the marginal swelling, the presence or absence of fold convergency and regenerative epithelium were studied serially in the following stages; before chemotherapy, when more than 50% (partial rosponse) of tumor reduction rate was observed (pre PR stage), and when partial or complete response was observed (PR stage, CR stage). Although we failed to find any uniform changes during chemotherapy like those seen in the course of benign ulcer healing, the morphological findings of the tumors in the PR stage could be classified into four types; no morphological change type, malignant fold type, mucosal change type and marginal swelling remaining type. Both the mean response period and survival period were found to be long in the following order; marginal swelling remaining type, mucosal change type, malignant fold type, no morphological change type. We, therefore, considered that the effect of chemotherapy on advanced gastric cancer could be evaluated by monitoring the morphological changes of tumors.

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We defined asymptomatic PBC (a-PBC) in which serum alkaline phosphatase level is less than twice the upper limit of normal range as "early PBC", and discriminated it from "classical PBC". In the present study, we investigated the laparoscopic findings in 17 cases of early PBC, and compared with those in 17 cases of classical PBC and 20 cases of symptomatic PBC (s-PBC). Numbers of patients in each histological staging (I, II, III and IV) according to Scheuer's classification were 14, 3, 0 and 0 in early PBC;10, 6, 1 and 0 in classical PBC, and 5, 6, 3 and 6 in s-PBC, respectively. Representative laparoscopic findings in overall PBC patients were reddish patch (48%), whitish marking (55%), and protuberance formation (59%). In patients with early PBC the presence of reddish patch and whitish marking was significantly low, and protuberance formation were relatively low as compared with patients with classical PBC. There were 6 patients (35%) with early PBC who showed no remarkable findings. Although we could not find any characteristic laparoscopic features in early PBC, at least one or two findings suggesting PBC were recognized in 9 of 17 (53%) patients. Of 10 patients who were laparoscopically folowed up, 6 showed some changes suggesting progression of disease on the liver surface. But 4 of the 6 patients were still asymptomatic. Therefore, it was suggested that some morphological findings precede the clinical findings in PBC.

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Endoscopic mucosal resection (EMR) is a useful therapeutic procedure for minute gastric cancer. However, EMR at C-region has been thought to be technically difficult compared with that at A-and M-region. We have made the efforts to solve these problems by following procedures; 1. an improvement of using instruments: 2 channel scope of forward-oblique view type (Olympus XGIF-2TK200, XGIF-2TK10) and new grasp forceps, 2. technical resources to control air volume in the stomach, 3. preparation for complication. We compared the outcome of EMR at the C-region using 2 channel scope of forwardoblique view type in recent 3 years (the recent period: 19 cases) with that in the former period (21 cases). Concerning the first EMR (Figure 1), only 5 of 21 cases (23.8%) were resected completely in the former period, whereas 13 of 19 cases (68.4%) were diagnosed complete resection in the recent period. There was statistically a significant difference between the both periods (P <0.01). Regarding the follow-up study, excluding 1 case who underwent subsequent gastric resection because of submucosal invasion, 12 of 20 cases (60%) were free of cancer, and the remaining 8 cases (40.0%) were recognized to have local residue or recurrence in the former period (Figure 2). One of these 8 cases had surgical gastrectomy, and the other 7 cases underwent endoscopic re-treatment, but in one case who had endoscopic retreatment the lesion rapidly developed into advanced cancer. In the recent period (Figure 3), 15 of 19 cases (78.6%) were well, and 4 other cases (21.4%) were noted to have local residue or recurrence. One of these 4 cases had surgical gastrectomy, and the remaining 3 cases underwent endoscopic re-treatment. We could recognized a tendency that clinical courses after EMR in the recent period were better than that in the former period, but statistically there was no significant difference. The incidence of complications was almost equal in the both period, and all of them consisted of minor hemorrhage except for one case with perforation. Two channel scope of forward-oblique view type was thought to be useful to conquer the difficulty of EMR at C-region.

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From September 1992 to October 1993, endoscopic variceal ligation (EVL) was performed in 35 cases of esophageal varices and 2 cases of bleeding gastric varices. EVL for esophageal varices with Red Color sign and for the bleeding esophagogastric varices was performed. The therapeutic goal was to attain F1 or F0 and negative Red Color sign. In all emergency cases of esophageal varices, bleeding was controlled. The rate of eradication of the varices by EVL only was 77.1%. EVL appears to be as effective as endoscopic injection sclerotherapy (EIS) in forms of eradicating esophageal varices. Additional EIS was performed in cases of varices which could not be eradicated by EVL only. Eradication was achieved in 88.6% of cases. The rate of eradicaton was higher in Child's A cases than in Child's B cases, and in prophylactic cases than in the emergent cases. There was no statistic significant difference in relation to variceal form or past history of therapy. No severe complication was observed with EVL for esophageal varices. It was considered that EVL should be the first choice of treatment for esophageal varices. However, it would appear that combined endoscopic sclerotherapy is necessary in certain cases, since we experienced reccurent cases. Further study is needed concerning gastric varices.

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We examined Helicobacter pylori (HP) infection in 30 patients (51-83y: an average age, and an avarage period of illness denoted 61.5y, 11.4y) with chronic renal failure undergoing regular hemodialisis (HD) and 29 patients (50-79y: an average age, and an average period of illness denoted 60.6y, 9.6y) non undergoing regular HD aspect of gastric mucosal atrophy by HP antibody in serum (IgG) and urease activity of the biopsy specimen from gastric mucosa. Nineteen patients were negative HP antibody in serum, and these atrophic stage showed C₁, O₃ by the atrophic pattern according to Kimura and Takemoto's classification in patients undergoing HD. Eleven patiensts were positive HP antibody in serum, and these at atrophic change showed C_{2, 3,} O_{1, 2} patterns in patients undergoing regular HD. Fifteen patients in 19 patients of negative HP antibody in serum showed C₁, and these patients have been performed undergoing regular HD over 6 years. Patients undergoing regular HD less than 1 months showed O₃, and patints undergoing regular HD less than 2 years showed C_{2, 3,} O_{1, 2} patterns. On the other hand, 8 patients non undergoing regular HD were negative HP antibody in serum, and these atrophic stage showed C₁, O₃ patterns. Six patients in 8 patients of negative HP antibody in serum showed O₃ pattern. Twenty-two patients undergoing regular HD were positive HP antibody in serum, and these atrophic change showed C_{2, 3,} O_{1, 2} patterns. In each age of patients whose undergoing regular HD, 7 patients of over 70 years old patients showed C₁ pattern. But, non undergoing regular HD patients did not show C₁ pattern in the same age group. These data suggest that patients undergoing regular HD may have not atrophic mucosa for their ages compared to the non undergoing regular HD patients, and this change may be correlated regular HD peiods. Also, urease activity of the gastric mucosa in patients with chronic renal failure showed the same results to HP anotibody in serum. The detection of HP has relation to its atrophic pattern. In conclusion, it was suggested that HP infection has related to the progress of atrophic change in patients with chronic renal failure similar to the influencing previous reports and the factor of the presence or not of HP in patient with chronic renal failure undergoing regular HD was the change of gastric mucosa by regular HD and the progress of atrophy by aging.

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Fine mucosal structure in the lower esophagus and at the squamo-columnar junction were studied in 73 patients with reflux esophagitis with magnifying electronic endoscope (Olympus, GIF-200Z). Discoloring esophagitis was defined as that the longitudinal vessels of the lower esophagus diappear before the squamo-columnar junction. Discoloring esophagitis was classified into four types, i. e., D type: only discoloring change in the lower esophagus compatible with a narrow definition as discoloring esophagitis, E type: regenerated epithelium converging in the esophagus, C type: regenerated epithelium converging in the cardia of the stomach, EC type: regenerated epithelium converging in both the cardia and esophagus. Duodenal ulcers and hiatal hernia were more frequently noted in active and healing stages than in discoloring and scarring stages. In active and healing stages fine cardiac mucosal structures classified into D pattern could not be found across the Z-line, and it changed to the normal BC pattern in scarring stage. Although discoloring esophagitis was found more frequently than we thought, clinical symptoms were few. Then, further study should be done pathophysiologically whether the classification "discoloring esophagitis" is needed or not.

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A 73-year-old female was hospitalized due to dysphagia and vomiting, Endoscopic examination showed stenosis at the lower portion of the esophagus. The surface of the lesion was associated with circular desquamation of the mucosa. On the eighth hospital day, she vomited a considerable amount of fresh blood. A second endoscopic examination revealed ulceration with white coating on an elevated lesion simulating a submucosal tumor. A radiographic study of the esophagus showed a compression image from the left side. CT scanning showed a f usif orm aneurysm but detected no fistula. On the 13th hospital day, she died of massive hematemesis. Autopsy revealed a fistula estimating 2.5 cm in diameter between the esophagus and an atherosclerotic aneurysm of thoracic aorta. We reviewed 20 cases of aorto-esophageal fistula including the present case. All cases complained of hematemasis. Of these, 18 cases died. Chiari's triad such as 1) chest pain, 2) signal bleeding and 3) mortal massive hematemesis were very common in these cases. It is suggested that emergency operations should be neccessary after the first signal bleeding.

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A 54-year-old man was detected small elevated lesion at the esophago-gastric junction on endoscopy. Histological study of the biopsy specimens showed many large atypical cells suggesting a sarcomatous lesion most probable. These atypical cells were immunohistochemically positive only for vimentin, and were negative for other tumor markers useful for identify the tumor cell origin. The lesion disappeared during the follow up studies, and the diagnosis of pseudosarcomatous granulation (PG) was made. It is important to recognize PG that may lead to an erroneous diagnosis of malignancy.

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A case of gastric carcinoma with intramural metastasis to the upper third of the esophagus was reported. The patient was 75 year old male, who was admitted to our hospital because of epigastralgia and dysphasia. Barium meal and endoscopic examinations revealed Borrmann type 3 cancer of the cardia, Borrmann type 2 cancer of the lower portion of the gastric body, and type ha cancer in the antrum. Furthermore, small elevation at the upper third of the esophagus was pointed out at the same time. Endoscopically biopsy showed adenocarcinoma from all of these lesions. Especially, the esophageal tumor was very similar to the lesion of the cardia. Total gastrectomy with removal spleen and pancreatic body and tail, blunt resection of the thoracic esophagus was carried out. Pathological diagnosis was triple gastric cancer with intramural metastasis to the esophagus. This case was very rare and only 5 cases of intramural metastasis to the lower esophagus had been reported by other authors.

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A 49-year-old man, diagnosed as having liver cirrhosis previously, was admitted to a hospital due to accumulation of ascites. Though the decrease of liver function was not severe, laboratory studies disclosed marked hypoproteinemia with a level of TP: 5.0 g/dl and Alb: 2.2 g/dl. Radiological and endoscopic examinations of stomach revealed multiple polyps from the body to antrum, and dropping of mucus from these lesions was observed. Histological investigation of polypectomied specimen revealed hyperplasia of surface epithelium and infiltration by inflammatory cell infiltration. Then, the patient was transferred to our hospital for further examination. We measured fecal α1-antitrypsin clearance and confirmed the protein-losing process in the gastrointestinal tract. Morphological examination of small intestine and colon did not show any abnormal features. All of these results suggested the gastric polyposis with protein-losing gastropathy. The measurement of fibrinolytic activity of the gastric mucosa showed high concentration of f ibrinolytic activity. Initially, antif ibrinolytic therapy with oral tranexamic acid had been performed, but it was ineffective. Therefore, cimetidine and irsogladine maleate were administered.About 3 months later, ascites and hypoproteinemia improved gradually while the gastric polyposis remained unchanged. It was reported that cimetidine has an inhibitory effect on protein-losing in the gastric mucosa by tightening the tight junction of gastric epithelium. In addition, it was reported that irsogladine maleate has the action of reinforcing and stabilizing intercellular binding in the gastric epithelium. Cimetidine and irsogradine maleate are positively available for the treatment of protein-losing gastropathy should be administed because of their stabilizing effect of the gastric epithelium.

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A 64-year-old man admitted with complaints of poor appetite, weight loss and general malaise. The liver was enlarged and serum alpha-fetoprotein (AFP) level was extremely elevated to 1, 213×103ng/ml. X-ray and endoscopic examinations revealed a Borrmann 2 type gastric cancer on the anterior wall of the upper body of the stomach. Multiple metastatic lesions of the liver were detected by CT scan. Angiography clearly showed the metastatic lesions with hypervascularity. In lectin binding analysis of AFP, non-binding fraction to concanavalin A was 6%, indicating that this tumor had hepatic differentiation. Biopsy samples taken from the gastric tumor showed adenocarcinoma having hepatoid feature and AFP was detected in the cells by immunohistochemistry. The patient was treated with chemotherapy and transcatheter arterial embolization (TAE) of hepatic artery, because widely-spreading tumors were not resectable. The primary tumor of the stomach nearly disappeared and metastatic lesions of the liver decreased markedly, resulting in survival for 19 months. It is concluded that chemotherapy and TAE should be done constructively as alternative treatment for AFP-producing cancer in patients who are unsuitable for surgical treatment.

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A 61 year-old man visited our hospital for examination of the large intestine. Barium enema X-ray examination revealed a broad-based tumor with smooth surface sized 15mm in diameter at the hepatic flexure. By colonoscopic observation, the tumor was yellowish and its surface was covered with normal mucosa with erythematous spots. Ultrasonographic examination with miniature probe demonstrated a tumor in the submucosa. Cystic anechoic areas and hypoechoic spots were present in a hyperechoic area. Endoscopic polypectomy was performed, and the histological examination of the resected specimen revealed dilated blood vessels of various sizes and loose connective tissue, supporting the diagnosis of hemangioma. Generally, hemangioma of the colon are usually resected with surgical operation. However, our experience indicates that small lesions of colonic hemangioma can be resected endoscopically when its indication is confirmed by ultrasonographic observation.

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We reported two patients with serrated adenoma containing well-differentiated adenocarcinoma in the colon. Case 1, a 56-year-old male was performed by colonoscopy because of persiting fecal occult blood. Endoscopic examination demonstated a villous, semisessile tumor of 3 cm in diameter in the rectum. This tumor was removed by endoscopic mucosal resection. Case 2, a 41-year-old male was also performed by colonoscopy because of fecal occult blood. Colonoscopic examination demonstated a villous, pendunculated tumor of 3 cm in diameter in the sigmoid colon. This tumor was removed by endoscopic mucosal resection. Histological examination of both specimens obtained by endoscopy revealed that these tumors are charactarized by serrated glandular pattern of glands, that was characteristic of hyperplastic polyp, but they are associated with histological dysplasia and cellular dysplasia. Therefore, these tumors were diagnosed as serrated adenomas. Further careful histological examination showed that both adenomas contained a small area of well-differentiated adenocarcinoma.

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Submucosal hematoma of the gastrointestinal tract can be formed during endoscopic examination. Two cases of colonic submucosal hematoma formed in the sigmoid colon resembling varices, were reported. We speculated that colonic submucosal hematoma could be formed when a stiffening cuff was intubated violently or a colonoscope was manipulated roughly. When mucosal separation between the superficial and deeper layers occurred, submucosal hematoma would be possibly formed. Though most cases of colonic submucosal hematoma are thought to heal spontaneously without any clinical troubles, there may be the possibility of massive bleeding from the hematoma. One should be always careful to do colonoscopic examination.

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A 83-year-old man was admitted to our hospital with complaints of lower abdominal pain, diarrhea, and melena. Digitale xamination revealed rectal bleeding and hard mucosa. We, therefore, suspected of rectal carcinoma. Endoscopic examination revealed mucosal edema and diffuse hemorrhage discontinnously in the rectum and sigmoid colon. Barium enema examination showed poor distensibility of the sigmoid colon, a rectal stenosis and irregular contour of the same area. Biopsy specimen showed marked mucosal hemorrhage, interstitial edema and inflammatory cell infiltration in the lamina propria. On the basis of these findings, the patient was diagnosed to have ischemic colitis with skip lesions in the rectum and sigmoid colon. We reported this case because ischemic colitis very rarely occurs discontinnuously in the rectum and sigmoid colon.

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We obtained the ultrasonogram of two minor papilla tumors with a sonoendoscope (7.5 MHz) and microprobe (20MHz). A correlation between the ultrasonic image and histological findings was discussed in a case which was completly resected with an endoscope. The resected specimen was composed of pancreatic tissue and Brunner's glands. Ultrasonography with a 20 MHz microprobe aftr injecting physiological saline into the submucosa was useful in deciding indication for endoscopic mucosal resection.

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