Since macroscopic change in ulcerative colitis (UC) is known to be non-specific, endoscopic diagnosis of UC is mainly based on the location and continuity of the lesion, i. e., serial involvement from the rectum. To clarify whether macroscopic change charac-teristic of UC never exist or do exist, 55 cases of UC were examined in total of 156 times with a magnifying video endoscope Fujinon EVC-HM during 2 years 4 months. Macro-scopic lesions were compared with their pathohistological and mucohistochemical changes using 528 biopsy specimens. As controls, 91 biopsy specimens were also examined from 13 patients without colonic disease. mucohistochemical change of lesions were examined by the high iron diaminalcian blue staining (HID-AB). Magnifying video endoscope revealed amall yellow spots in active area of slight illness (Matts' grade 2), and in marginal zone between active and inactive areas of moderate to severe illness (Matts' grade 3 to 4). These spots disappeared with a remission after treatment and re-appeared with a recurrence. Pathohistologically these spots showed focal destruction of colonic glands with severe infiltration of neutrophils. Moreover, a focal area showing small yellow spots was not infrequently (41.8%) observed in oral-sided mucosa of the colon apart from the active area intervening normal mucasa A lesion like this was consistent with a "skip ped lesion." In the normal colon, colonic glands preferentially had sulphomucin. By contrast, colonic glands in active stage of UC preferentially had sialomucin. The rate of sialomucin expression was similar between active areas of UC and skip ped lesion, suggesting that skip ped lesion was mucohistochemically equivalent to active area of UC. The finding of small yellow spots seemed to be characteristic and could be an indicator suggesting UC in the endoscopic diagnosis. The existence of skip ped lesion as active colitis may ask need to revise the present classification of disease type in UC.

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Electric endoscopic image signals of rectal mucosa were sampled using a still video recorder (Fujix, R5000-MH) under usual observative conditions. Images were processed after 8-bit A/D conversion using an image processing unit (Olympus, SP-1000), and rectal mucosal hemoglobin index (HI) was defined as a parameter for microcirculation. Hemoglobin index (HI) was determined as logarithms of G-signal (Vg)/R-signal (Vr) ratios in regions of interest on electric endoscopic images. [HI=32⋅log. (Vg/Vr)] At the same time, histological findings of biopsy specimens collected from rectal mucosas were compared to HI values obtained in these areas. All samples were amounted to 149 cases. Rectal mucosa was histologically obseved on 5 headings. (1) inflammatory cell infiltra-tion, (2) intramucosal bleeding, (3) erosions, (4) number of blood vessels and (5) vascular diameter were observed. Mean HI values showed significant intergroup differences. The group of predominant inf lamatory cell infiltration shows high HI value. The groups of intramucosal bleeding and erosions showed higher HI value. And thick vascular diameter and large number of blood vessels affect HI value. HI values were low in patients with chronic constipation and high in those with diarrhea.

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To investigate characteristics of atrophic gastritis in patients with autoimmune liver disease (ALD), endoscopic congo red-methylene blue tests combined with histological examination were carried out in 24 patients with ALD (including 16 patients with primary biliary cirrhosis (PBC) and 8 patients with autoimmune hepatitis (AIH)), 28 patients with chronic liver disease (CLD) and 33 healthy controls. Parietal cell antibody (PCA) was detected by indirect immunof luorescent test. Serum gastrin levels were also measured. The open type of endoscopic atrophic border was found in 75.0% of patients with ALD, 53.8% of CLD and 48.5% of healthy controls. It suggests that severe gastric mucosal' atrophy was frequently seen in ALD (p<0.05) as compared with others. Intestinal metaplasia was also found extensively in patients with ALD. In the study of serum autoantibody, PCA was found in all of 16 PBC patients (100%), 6 of 8 (75%) AIH patients, 8 of 28 (28.6%) CLD patients and 4 of 33 (12.1%) healthy controls. Serum PCA seems to be common in patients with ALD. The titer of PCA in patients with ALD was also significantly (p <0.001) high, as compared with others. Fasting serum gastrin levels were 160.4±163.4 pg/ml (n= 22) in patients with ALD, 77.6±42.9 pg/ml (n=18) CLD and 81.7±38.0 pg/ml (n=25) healthy controls. Serum gastrin level was significantly higher in patients with ALD (p <0 .05). In conclusion, severe and extensive gastric mucosal atrophy is one of characteristics of gastric lesions in ALD. PCA may be associated with the pathogenesis of this gastric mucosal atrophy. It was suggested that hypergastrinemia was induced by hyposecretion of gastric acid which was caused by severe and extensive fundic mucosal atrophy in relation to destruction of parietal cells.

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Twenty one patients undergoing surgical treatment for rectal carcinoma were examined by means of the first prototype model of MR endoscope (designed and provided by Yokokawa Medical Co. and Olympus Opt. Co., Tokyo, Japan) for the staging before surgery. The same patients also underwent the staging with endoscopic ultrasonography (EUS) before surgery. As a surface coil at the tip of antenna probe was accurately positioned on the cancerous lesion using non-magnetic fiberscope, all lesions were detected by MR endoscopy. The whole rectal wall was apparent as 3 or 5 layers on images obtained with 3D fast SPGR method of MR endoscopy. The diagnostic accuracies in detection of rectal wall infiltration by MR endoscopy were 100% (2/2) in the cases in which cancerous invasion was detected in the submucosa by MR endoscopy, 50% (3/6) in those of the muscularis propria, 83% (10/2) in those of perirectal fat, 100% (1/1) in those of the adjacent organs and 76% (16/21) in all cases. The diagnostic accuracies in detection of rectal wall infiltration by EUS were 100% (3/3) in the cases in which the cancerous invasion was detected in the submucosa by EUS, 57% (4/7) in those of the muscularis propria, 90% (9/ 10) in those of perirectal fat, 100% (1/1) in those of the adjacent organs and 81% (17/21) in all cases. The sensitivity of MR endoscopy in detection of lymph node infiltration was 85.7% ; specificity, 61.5% ; and accuracy, 70.0%. EUS showed the same sensitivity, specificity and accuracy. These findings suggest that MR endoscopy may be as accurate as EUS in the preoperative staging of rectal carcinoma. In comparison with EUS, MR endoscopy has multiplanar capabilities and wide scanning area. But, MR endoscopy needs MRI apparatus and MR imaging cannot be acquired in real time. The improvement of MR endoscope is desired.

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Endoscopic ultrasonography (EUS) was performed on nine cases (eight primary and one secondary of gastric malignat lymphoma). Pathological specimen were obtained during surgery in six and by biopsy in two of the eight patients with gastric primary malignant lymphoma. When the efficacy of EUS in these nine patients was studied, the following results were obtained. (1) In the eight cases of gastric primary malignant lymphoma, comparatively homogenous low echos were obtained in the giant fold type (one case), protruded type (one case) and ulcerative type (two cases), an differentiation from gastric cancer and ulcer was possible using the echograms, but such differentiation was not possible in the superficial spreading type (three cases). (2) The depth of invasion could be correctly diagnosed in four of the six patients undergo in surgery. The one patient who was misdiagnosed had microinfiltration to the proper muscle layer which was confirmed by immunostaining using a monoclonal antibody. (3) Preoperative diagnosis was possible in one patient with lymph node metastasis. (4) In one patient with gastric secondary malignant, lymphoma, the presence of infiltration was confirmed only by EUS.

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We have examined the esophageal varices in 49 patients (Fl ; 25, F2 ; 21, F3 ; 3) by a new technique of endoscopic ultrasonography (EUS) which used with a miniature ultrasonic probe, providing a rapid and accurate assessment of the varices. EUS could successfully display all the varices as low-echoic images in the esophageal wall, and in 20 high risk patients (F2 accompanying red color sign; 17, F3 ; 3) vessel images were discovered with the sizes larger than 3 mm in diameter. Fifteen of them underwent endoscopic injection sclerotherapy. These vessel images were then reduced to less than 3 mm in diameter after therapy (average number of sessions ; 2.7), and additional sclerotherapy (mean number of sessions ; 2.0) was administered for varices less than 3 mm in diameter to achieve eradica-tion. Five patients received one session of endoscopic variceal ligation, and in 3 of them the varices had become smaller than 3 mm in diameter. In 16 patients, 42 lesions of thrombotic varices were diagnosed by endoscopy. In 16 cicatrized lesions the veins were not displayed by EUS. But in 10 of 26 lesions having varicose form, vessel images were still visualized by EUS. We, therefore, recommend EUS by miniature probe technique for improved determination of the clinical effects of sclerotherapy.

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A comparative study of the endoscopic ultrasonography (EUS) findings and the pathological data was performed in four patients with ectopic gastric pancreas. Tissue was obtained for pathological examination when these patients underwent surgery for gastric malignant lymphoma, early gastric cancer, ovarian cancer, and on the patient's request, respectively. The ectopic pancreas was mainly submucosal in one case, while it involved the submucosal and proper muscle layers in two cases, and extended from the mucosal layer to the proper muscle layer in one case. Among the three patients with ectopic pancreatic tissue in the proper muscle layer, thickening of this muscle layer was found on EUS in two cases. The pancreatic tissue and the proper muscle layer were imaged as a single mass in the third patient, and marked abnormality of the muscle layer was noted. On EUS images, the margins of the ectopic pancreatic tissue were unclear in all cases, and the internal echo patterns and echogenicity were variable. The reason for this appeared to be marked differences in the density and proportion of the glandular and excretory duct elements forming the ectopic tissue. Tissue with a dense growth of acinar cells showed reduced echogenicity. Excretory ducts were imaged as sporadic small hypoechoic lesions and cyst-like images were obtained in two patients with marked ductal dilatation.

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Vascular lesions of the colonic mucosa were studied endoscopically in 37 patients with portal hypertension. The characteristic findings of colonoscopy in these patients and their incidence rates were : vascular ectasia, 62.6 % ; dilated fine branching vessel, 86.5% ; blue vein, 51% : and rectal varices, 21.6%. We studied the relation of the prevalence of each finding to the degrees of esophageal varices, Child-Pugh classification and ICG R₁₅ value. There was a tendency that vascular ectasia was found in patients with advanced esophageal varices of F₂ and F₃. The various findings of biopsy specimens in these patients and their incidence rates were : mucosal congestion, 51.4% ; mucosal edema, 32.4% ; and mucosal or submucosal dilated capillaries, 16.2%. No remarkable change in endoscopic findings of the colon was observed after the endoscopic injection sclerotherapy (EIS).

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A case of advanced gastric cancer showing the features of submucosal tumor and with no definite diagnosis before surgery is reported. The patient was a 44-years-old female with a presenting complaint of epigastralgia; a submucosal tumor-like lesion with ulceration on the posterior wall of the gastric angular region was detected. Histological examination of this lesion by means of endoscopic biopsy and boring biopsy after strip biopsy suggested a group I lesion, but possibility of a malignant lesion was also considered. Therefore, a subtotal gastrectomy was performed. After the operation, pathological examination revealed a signet-ring cell carcinoma with invasion to SS and lymphnode metastasis. Fifty-four cases of gastric cancer simulating submucosal tumors have been reported in Japan. But cases in which the chief component of the protrusion is collagenous fiber are very rare.

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A-64-year old breast cancer patient was admitted to our hospital for post-operative chemotherapy due to bone metastasis. She was operated on 5 years before. We administered to her Adriamycin (ADR), 5-Fluorouracil (5-FU), Cyclophosphamide (CPA) and Medroxyprogesterone Acetate (MPA).
After administering a total dose of ADR (90mg), 5-FU (1500mg), CPA (900mg), and MPA (14400mg), she developed nausea, vomiting, chest pain and hematemesis. Endoscopic examination revealed mucosal dissection of posterior wall of the esophagus extending from E-G Junction to the upper part of the esophagus. Conservative management with IVH and administration of antacid drugs improved her clinical course gradually. Follow up endoscopic examination 1 month after hematemes revealed restoration of esophageal membrane.

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A case of a 50-year-old male with two early esophageal and two early gastric cancerous lesion is reported. The surgical operation was performed. The pathological diagnosis was as the following. Esophageal cancer ; 0-IIc+IIa lesion was located in the inferior thoracic esophagus, and the depth, sm₂ the other was 0-IIc lesion located in the middle thoracic esophagus, and the depth, mm₂. Gastric cancer ; the one was I+IIa on the upper body, and the depth, sm. The other was IIc on the antrum, and the depth, m.

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A 21-year-old female admitted with complaint of epigastric pain in December, 1991. Serum AFP level was elevated to 66.1 ng/ml (Table 1). X-ray and endoscopic examination (Figure 1, 2) showed Borrmann type 3 carcinoma which was located from the cardia to the lesser curvature of the upper body of the stomach. Liver metastasis was not detected by CT and ultrasonography. Total gastrectomy was performed. Spotty metastases were found on the surface of the liver in surgery. The resected specimen showed 7.2 x 5.3 cm in size, and it showed histologically papillary adenocarcinoma (Figure 5). Immunohistochemical studies showed that locations of AFP were found in the cancer cell stained by immunohistochemical method. Postoperative serum AFP level decreased to normal range transiently. There are a few case with papillary adenocarcinoma of the stomach in young adults under 30 years old. In Japan, only 6 cases including this one have been reported, and this is the first report of AFP producing papillary adenocarcinoma of the stomach in young adults.

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Few cases of malignant tumor of the small intestine diagnosed preoperatively have been reported, in spite of the developement of endoscopic examination. We experienced one case of malignant lymphoma located 220cm distal to the Treitz Ligament. A patient was admitted to our hospital with a chief complaint of abdominal fullness. The diagnosis of malignant lymphoma could be made preoperatively by peroral enteroscopy under a sliding tube guidance, and was confirmed by histologic examination. This was the case most distally located from the Treitz ligament among the cases of malignant tumor of the small intestine diagnosed preperatively. Peroral enteroscopy is the most useful procedure in the preoperative diagnosis for small intestinal malignant tumors.

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A 54-year-old male received colonoscopy elsewhere, becanse of positive fecal occult blood testing at a medical check-up. The colonoscopy showed the presence of a tumor in the vicinity of the ileocecal valve. The patient was then referred to this department, and hospitalized for further examination. Colonoscopy confirmed the presence of a tumor, about 4cm in size, near the ileocecal valve. At that time, it was observed that the tumor regressed to the ileum through the ileocecal valve. A sphenoid resection of the ileum was carried out, and the tumor was histopathologically a tubular adenoma. The report includes a number of observations concerning small bowel tumors.

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The patient was a 68-years-old woman with main complaint of epigastralgia. She was hospitalized because upper gastrointestinography and gastroscopy revealed stomach cancer of ha +IIc type in the ventral wall of gastric vestibule. Culture of tubercle bacillus in stools was positive and Barium enema and colonoscopy also demonstrated the specific characteristics of colon tuberculosis in the transverse colon. We performed the operation with a strong suspicion of active colon tuberculosis, then, lymph nodes associated with tuberculosic inflammation were found at the root of the middle colic artery and the above diagnosis was established. Remission of colon tuberculosis was developed by postoperative chemotherapy.

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A 34-lyear-old female visited our hospital with complaint of melena, and was diagnosed to have a submucasal tumor in the terminal ileum by X-ray and endoscopic studies. Ileocecallectomy was performed. The tumor was 10 x 9 x 8mm in diameter and consisted of white solid tissue. Microscopically, the tumor had no capsule and consisted of fusiform cells. The tumor cells revealed positive immunoreactivity to s-100 protein and NSE, on the other hand, negative to desmin and myoglobin. They also revealed positive to Alcian blue and had no seatlike structure of nuclei, so were diagnosed as neurof ibroma. Nourogenic tumor of the small intestine is very rare, especially without complication of von-Rechlinghausen disease. Thus, it is very difficult to make the diagnosis of neurof i-broma before operation like this case.

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A 45-year-old housewife with a 10-year-history of systemic lupus erythematosus (SLE) was admitted on 2 December 1992, complaining of fever, mucocutaneous ulcerations, and anal pain. She was diagnosed as exacerbation of SLE because of clinical features and immunologic abnormalities. Though oral dosage of prednisolone (PSL) was increased, massive hematochezia developed on 15 December. Emergency colonoscopy revealed hemorrhage from the round-shaped discrete ulcer with normal surrounding mucosa, so-called “punched-out ulcer”, in the descending colon. We chose hemoclipping for hemos-tasis, but clipping procedure was difficult because of diffuse hemorrhage from the ulcer floor. Our methods were as follows ; (1) Hooking the one clip end at the anal margin of the ulcer. (2) Approaching the other end to the oral margin of the ulcer by pushing the forceps. (3) Planting the clip. After these procedures, the open ulcer was successfully closed. The 2nd colonoscopy on 25 December showed complete hemostasis and multiple various-shaped ulcers in the rectum and sigmoid colon which had not been observed due to residual blood on the 1st colonoscopy. Biopsy specimen taken from these ulcers suggested the etiology of ulcers was lupus vasculitis. The therapy with intravenous administration of PSL (100 mg daily) and hyperalimentaion induced remission of SLE and healing of cob-rectal ulcers.

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A 49-years-old man with fungal endophthalmitis was admitted because of elevated bile ductal enzymes and abnormality of gallbladder wall demonstrated by abdominal ultrasonography (US). 2 months ago he had colectomy for colon cancer. By endoscopic US (EUS) on admission, GB was enlarged and the, normal structure of the wall disappeared. One month later, GB was contracted and the wall was thickened with the irregular 3 layers structure. The cholecystectomy was performed and the histological findings revealed xanthogranulomatous cholecystitis (XGC) in the whole of GB wall. In this case, the typical findings of XGC and its serial changes were obtained by EUS.

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A 53-year-old man was seen at Matsue Red Cross Hospital with the chief complaint of abdominal full sensation. Barium enema examination revealed a narrowing and irregularity of the wall, 8 cm in length, in the sigmoid colon. Colonoscopy demonstrated a narrowing stricture with edematous mucosa. The biopsy specimens obtained only from a fissuring demonstrated well differentiated adenocarcinoma. The resected specimen showed a poorlydefined elevated lesion, 7 × 3cm in size, with a coarsely granular appearance of the mucosa surrounded by converging folds. Most of the tumor was covered with noncancerous tissue. Histologically normal colonic mucosa was present in the submucosa involved by tumor.

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A 61-yr-old woman was admitted to our hospital with complaints of jaundice and intermittent pain in the right upper abdomen. Ultrasonogram showed multiple stones and debris in the distended gallbladder, and a dilation of the common bile duct (CBD). The diagnosis of obstructive jaundice was then made. After that, endoscopic nasobiliary drainage and endoscopic sphincterotomy were performed, and a stone was removed from CBD. Cholangiography demonstrated an obstruction of the cystic duct, and non-visualization of the gallbladder. EUS demonstrated a dilatation of CBD and a papillary lesion at the site of the obstruction. However, PCS and brushing cytology could give a definite diagnosis of carcinoma in the cystic duct. Multiple stones in the enlarged gallbladder and a tumor in the cystic duct were found after laparotomy. Extended cholecystectomy and lymphadenectomy were carried out and a T-tube was inserted. Combination of EUS, PCS, and transpapillary biopsy and cytology is thought to be very useful to make a differential diagnosis of obstruction of the cystic duct. In this case, although the main tumor seemed to be in the cystic duct of the gallbladder macroscopically, however in a pathological viewpoint, adenocarcinoma had invaded a large part of the gallbladder and the depth of tumor invasion had been limited to the subserous layer.

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We used Histoacryl (n-butyl-2-cyanoacrylate) as an embolization material on trans-catheter arterial embolization (TAE) for bleeding gastric and duodenal ulcers in which endoscopic hemostasis was unsuccessful, and assesed its efficacy and adequete use. Angiography was performed on 5 occasions in 4 patients with bleeding gastric and duodenal ulcers for which endoscopic hemostasis failed, and hemostasis by TAE with Histoacryl was done with success. Coils were used with Histoacryl in 3 occasions, and only Histoacryl was used in 2 occasions. Only 1 case in which the extravasation of contrast materials was not detected and bleeding artery was not identified showed rebleeding and operation was performed, but complete hemostasis was achieved for the remaining 4 cases. Although some consideration is needed about the use of coils, the mixing ratio with contrast materials etc., we concluded that Histoacryl, a compound of cyanoacrylates, which has been used as a tissue adhesive in surgery, an injection material on the sclerotherapy for varices, is a useful embolization material for TAE for bleeding gastric and duodenal ulcers, especially in endoscopically uncontrollable cases, because Histoacryl makes it possible to embolize completely an artery for a long strech in a short period.

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