A comparative review was made on the period of time before relapse between 39 cases treated with the endoscopic injection sclerothetapy (EIS) and 31 cases treated with the endoscopic variceal ligation employing a clipping apparatus (EVL-c) combined with EIS for esophageal varices. All of the patients had been observed for over 6 months after the initial therapy. Moreover, stadies was made of factors related to relapse, using multivariate analysis. The results of combined use of EVL-c with EIS were compared those of EIS alone. The average total dosage of sclerosing agent was relatively small (32.3 ml) and the average length of treatment was relatively short (4.69 weeks). The relapse of varices was found to be not related with the total dosage of sclerosing agent, total number of clips used, hepatic function, complication with hepatocellular carcinoma, or alcohol intake. Relapse occurred significantly only in cases whose treatment was combined with EVL-c (p<0.01). The average sclerosing agent dose per week for therapy was less than 7 ml, and in cases when the sclerosing agent dose per clip was over 5 ml, the non-relapse period was found to be extended. Examined by endoscopic ultrasonography revealed that threated EVL-c combined with EIS showed a thickness of 2 mm of esophageal mucosa. Pathologically, esophageal mucosa after combined therapy exhibited less fibrotic changes. When EIS was combined with EVL-c, such merits as decrease in the amount of sclerosing agent used and shortening of the curing period were seen. However, the period of time until relapse was shorter than that with EIS alone. Thus, in order to extend the period until relaps, findings of F1 and RC (-) should not be regarded as the end of therapy. Indeed, it might be necessary to continue para-variceal injections for a longer time.

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To evaluate changes in color tone by pharmacoendoscopy, spraying epinephrine on ulcer scars, the time course of color changes was studied based on mocosal blood volume using image analysis. The changes in color tone after pharmacoendoscopy was classified into two groups, P_R (redness) and P_W(completely pale). The percent decrease in mucosal blood volume of red scars after the spray of epinephrine was significantly lower than that of white scars and normal mucosa. Comparison of pharmacoendoscopic findings with the changes in mucosal blood volume after the spray of epinephrine revealed that the percent decrease in mucosal blood volume immediately after the spray was lower in the P_R group than that in the P_W group, and normal mucosa. Moreover, the mucosal blood volume in the P_R group before the spray of epinephrine was 1.2 times as much as that of normal mucosa, but after the spray the value increased to about 1.4 times. However, in the P_W group there was no remarkable change in the mucosal blood volume of the scar region compared to normal mucosa. The change in color tone by pharmacoendoscopy, could be quantified by image analysis, and was suggested to correlate with mucosal blood volume.

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A new technique of sclerotherapy for esophageal varices, a mucosa-fibrosing method with Laser after EO-AS combination method was applied to 11 patients and the results obtained were compared with those obtained by a mucosa-fibrosing method with AS. A mucosa-fibrosing therapy for esophageal varices consists essentially of complete disappearance of esophageal varices using the EO-AS method followed by fibrosing the lower esophagus with AS. The mucosa-fibrosing method with Laser was developed by replacing AS injection with laser irradiation. Laser irradiation is conducted with an output of 13 Watt and a pulse duration of 1 sec or less. The 11 patients were treated one to six times (mean: 3.4 times) using 828-6, 306 J per time (mean: 2, 250 J). The whole of the lower esophagus was irradiated, including thrombotic varices and normal esophageal mucosa. The laser mucosa-fibrosing method was easier to manipulate than the AS mucosa-f fibrosing method and could cause shallow and uniform ulcerations. This method could make thorough fibrosis in the esophageal wall without esophageal stenosis. No recurrence was seen in 11 patients after the laser mucosa-fibrosing method during the observed 17 months, the longest. Therefore, this method is safe and effective.

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A 74-year-old male was admitted because abnormal ahadow was suspected on chest X-ray of health examination. An advanced esophageal cancer was detected by upper gastrointestinal endoscopic examination. Abdominal CT scan revealed two metastatic liver tumor. This case was diagnosed as esohageal cancer with lung and liver metastasis. We considered this case an indication for chemotherapy. PV therapy (Cisplatin 80mg on the first day and Vindesin 3mg on the first and eight day) were carried out 6 times. To add to it, oil-Bleomycin suspension was given as oral preparation. After 1st PV therapy, lung metastatic tumor disappeared. After 6th PV therapy, esophageal cancer became scarring and no liver tumor was detected by abdominal CT scan. Although this case was supposed to be poor-prognostic at the first time, PV therapy and oil-Bleomycin suspension provided him prominent improvement.

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A 65-year-old female was admitted to our hospital with complaints of pretibial edema and loss of weight. Upper GI series and gastrof iberscopy revealed multinodular tumors occupying the gastric body. Laboratory tests showed hypoproteinemia, hypoalbuminemia, microcytic hypochromic anemia and thrombocytosis. Fecal excretion and clearance of alpha 1 antitrypsin were high. ¹¹¹In-C1₃ scintigraphy showed activity in the gastrointestinal tract. Total gastrectomy was performed and multinodular tumors, measuring 12×18cm as a whole, were found in the gastric body. Histological study of the tumors revealed well differentiated tubular adenocarcinoma showing villous growth and abundant mucous production in part. Hypoproteinemia, hypoalbuminemia, anemia, thrombocytosis, fecal excretion and clearance of alpha 1 antitrypsin, and ¹¹¹In-C1₃ scintigraphy were normalized after the operation. These facts indicated that serum protein leaked from the gastric cancer, resulting in severe hypoproteinemia. A review of Japanese literature with cases of gastric cancer associated with severe hypoproteinemia is described.

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A 55-year-old man was admitted to our hospital on December 31, 1989, complaining of general fatigue and abdominal fullness. Plain abdominal roentogen examination revealed-marked sand-grain calcification in the left upper abdomen. Upper GI series showed the narrowed gastric cavity and irregular surface of the gastric wall. US and CT study revealed massive ascites in abdominal cavity, and hypertrophic gastric wall in which hyperechoic area was observed, and it was considerd as the calcification. The calcification of the gastric wall was markedly increased in about 3 months after admission. On endoscopic examination, the gastric cavity was not elastic from the body to the pylorus, and folds showed hypertrophic with mucosal reddning and erosions. We diagnosed it Borrmann type 4 gastric cancer. Histological study of the biopsy specimens disclosed signet-ring cell type carcinoma and mucinous adenocarcinoma was shown on autopsy. The calcified gastric cancers detected by plain abdominal roentogen examination are rare, and only 63 cases have been reported in Japan. In this paper we report a such case referring to the literature. In almost all of these cancers, macroscopic feature were Borrmann type 3 or type 4, and mucinous adenocar-cinoma or signet-ring cell type carcinomas were common on histology. All of these cases were advanced carcinomas, so survival time were not so long.

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An 80-year-old male had been followed up for gastric ulcer. In January 1993, endo-scopic examination revealed two ulcerative lesions on the posterior wall of the lower gastric body. Histological examination of the biopsy specimen showed malignant lymphoma. Although the lesions healed after 2 months, new erosion developed on the posterior wall of the angle. Histological examination of the biopsy specimen again showed malignant lymphoma. The diagnosis of diffuse large cell lymphoma was made, and total gastrectomy was performed. On histological examination of the resected specimen, the two ulcerative lesions showed marked fibrosis (U1-IIs) without lymphoma cells and the erosion on the posterior wall of the angle showed infiltration of the lymphoma cells. The focus of malignant lymphoma was noted only small parts of the lesion (0.2 x 0.3 cm). In this case, gastric malignant lymhoma took a course of so-called "malignant cycle" type. Therefore, careful diagnosis and treatment for early gastric malignant lymphoma should be needed because spontaneous regression may occur in early gastric malignant lymphoma.

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Extramedullary plasmacytoma of the stomach is an extremely rare disease, and only about 50 cases have been reported in Japan. This is a report of a case of gastric plasmacytoma limited to the mucosal layer which was difficult to distinguish from RLH and malignant lymphoma. A 61-year-old woman visited our hospital with complaint of occasional epigastric pain. Endoscopic examination revealed the discoloured mucosal lesion on the lesser curvature from the lower body to the angle, the boundary of which was unclear, and it was accompanied by multiple redness and erosions. Because the biopsied specimen disclosed the finding of plasmacytoma, we performed total gastrectomy. In resected specimen, atypical plasma cells were widely seen from the body to antrum. Immunohistochemically these cells were monoclonally stained with IgM and x-light chain, but they were confined to the mucosal layer. This gastric plasmacytoma limited to the mucosal layer was the fourth report in Japan. According to reports of the advanced cases, the prognosis was not good at all. So the early diagnosis is desired.

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Two cases of heterotopic gastric mucosa in the duodenal bulb were incidentally detected ; the one, 50-year-old male on X-ray examination in a health-check and the other, 46-year-old male on screening endoscopy conducted before operation. Acid secretion from the heterotopic gastric mucosa was proven using the Congo red dye spraying method at endoscopy. The features of acid-secreting heterotopic gastric mucosa in the duodenal bulb were studied endoscopically in 7 cases included the two noted above. In each case, the acid-secreting heterotopic gastric mucosa was detected such as multiple, granulated and mildly elevated lesions on the proximal part of the duodenal bulb without other lesions.

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A case of hemorrhagic rectal ulcer complicated with simple ileal ulcer is reported. Bloody stool developed while the 21 year old male patient was treated for hypoxic encephalopathy and in a severely ill condition. Colonoscopic examination revealed a bleeding ulcer localized in the distal rectum and the terminal ileum. Hemostasis by ethanol injection and heater probe was achieved successfully. The rectal ulcer was diagnosed as an acute hemorrhagic rectal ulcer because its endoscopic findings were very similar to those reported by Kohno et al. The ileal ulcer was diagnosed as a simple ileal ulcer based on endoscopic findings and confirmed thereafter with histological findings and laboratory data. This case shows that stress and severely ill condition inducing rectal ulcer could be complicated with simple ileal ulcer. It was speculated that the similar stress mechanism may be involved for the occurrence of these ulcers in the two distant parts of the intestinal tract. Thus we suggest that when emergency colonoscopy is performed for the diagnosis of lower GI bleeding, careful examination of the terminal ileum may be necessary together with routine colon examination.

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A 66-year-old man with a complaint of left lower abdominal pain admitted to our medical center. An intraperitoneal abscess with sigmoid fistula was diagnosed by Barium enema, CT and colonoscopy. A sigmoidal fistula was not detected macroscopically during operation, but intraoperative colonoscopy revealed whitely coated spot and proved it to be an entry of the colonic fistula. The final diagnosis obtained by pathological findings was an appendico-sigmoid fistula due to acute appendicitis. Twelve cases of appendicoenter-of fistula have been reported in Japan. Barium enema has been said to be useful for the diagnosis of this disorder. But in our case endoscopic examination was more valuable for the diagnosis and treatment.

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The patient was a 76-year-old male in whom fecal occult blood test reaction and an ileal polyp found by colonoscopy (CF) . Endoscopic findings revealed, disclosed intussusception in the ascending colon resulting from progression of the polyp in the small intestine. X-ray examination showed a semipedunculated polyp in the ileum approximately 30cm from the ileocecal valve. Pathological findings showed the presence of a semipedunculated polyp (35 × 25 × 15 mm in diameter) with lobulated surface. Histological examination showed tubular adenoma with moderate atypia, but malignancy was not confirmed. Since ileal adenoma is comparatively rare, we consider this case to be a valuable one and report it here with a brief review of the relevant literature.

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A 70-year-old male complaining of fever and diarrhea was admitted to our hospital. Colonoscopic examination showed a pedunculated polyp in the ascending colon close to the hepatic flexure, and endoscopic polypectomy was performed. The polyp had smooth white surface and was 6×5mm in diameter. Histologicaly, the polyp was an inflammatory fibroid polyp showing proliferation of f ibroblasts and infiltration of inflammatory cells such as plasma cells and eosinophils. Inflammatory fibroid polyp of the colon is very rare, and so far 7 cases have been reported in Japanese literature.

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A 47-year-old female suffered from erosions in the oral cavity and bullae on the skin of trunk. A diagnosis of pemphigus vulgaris was made by the histological findings and direct immunof luorescence examinations of the bulla. Erythema nodosum was also found on the lower legs. In the course of pemphigus vulgaris, she sufferd from diarrhea and stool occult blood examinations continued to be positive. Barium enema examination and colonoscopy were performed and the diagnosis of ulcerative colitis was confirmed. Autoimmune mechanism has been involved in the pathogenesis of pemphigus vulgaris. Ulcerative colitis is also considered to have some autoimmune aspects. We have reported a rare case of ulcerative dolitis associated with pemphigus vulgaris and erythema nodosum.

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A 43-year-old man was admitted for variceal bleeding due to alcoholic cirrhosis. Bleeding from esophageal varices was controlled after 3 sessions of endoscopic sclerotherapy. But hemorrhage from portal hypertensive gastropathy was occurred after sclerotherapy and was not controlled by medical treatment. An emergency transjugular intrahepatic portosystemic shunt was successfully performed and a subsequent arrest of acute hemorrhage. Transjugular intrahepatic portosystemic shunt may become an useful treatment for hemorrhage from portal hypertensive gastropathy.

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According to the recent progress of endoscopic mucosectomy technique for the esophagus, mucosal cancers of the esophagus can be treated by the mucosectomy as a completely curable resection. In order to evaluate preoperatively the depth of superficial esophageal cancer invasion as accurately as possible, we introduced 20-MHz miniature probe (Prototype, Olympus) combined with water-filling technique using anal side-occlusion balloon attached to the outer wall of the videoendoscope. By employing this technique clear sonographic view sufficient to evaluate precise structure of the esophageal wall was easily obtained, showing 7-or 9-layers structure. We applied this examination to 6 cases of superficial cancer and one case of granular cell tumor. In each case clear sonographic view was successfully obtained without any complaints. The muscularis mucosae was estimated to be equivalent to the fourth low echoic layer among 9-layers structure. Each lesion was identified as the destruction of normal sonographic layers.

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For treating of an early gastric cancer (EGC), there are surgery and several endoscopic methods. Recently, a minimum invasive therapy has been emphasized for treating a diseases. Although an endoscopic therapy is the most preferable method for treating an EGC for this purpose, it has a limit of indication. For the treatment of an EGC, the most adequate method should be selected, based on the condition of the primary lesion, metastasis and general condition, after getting informed consent from the patient. An EGC with lymph node metastasis has to be surgically resected, including its metastasis, but an EGC without it has to be treated by endoscopic method, as far as possible. The best indication of endoscopic treatment for an EGC is the lesion without lymph node metas-tasis, localizing at the mucosal layer or infiltrating only to the superficial part of the submucosal layer (sm 1), within 1.5 cm in size, without a coexistent ulcerous lesion and composed from well differentiated adenocarcinoma. The lesion with these conditions is is called the absolute indication of the treatment of an EGC and should not be operated by surgery. Out of the lesions with the absolute indication, a superficial or flat type has to be treated by an endoscopic mucosal resection (EMR) and a pedunculted type by an endoscopic polypectomy. There is the other endoscopic method for the treatment of EGC, called a non endoscopic resection method (non-ER) or destruction method. Laser endoscopic method is the typical one of non-ER. Although it destroys the lesion and cannot collect it, it makes possible rather easier technique and more exact effect, with few accident, such as perforation. Non-ER becomes a good indication for EGC of patient with high surgical risk or patient refusing surgery, especially for a lesion beyond the absolute indication, called the relative indication, in these patient.

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To search for the Royal Road would be to make researches in a way how to make a correct diagnosis. The fundamentals of X-ray diagnosis depend on the size, elevation or depression and site of the aimed lesion. Endoscopically, color of the lesion is added. Surgeons and pathologists regard depth of invasion and histological type of the lesion as important. Making a correct diagnosis, all of these fundamentals are important respectively. Trying to diagnose a carcinoma in earlier stage, we have to find a lesion less than lcm in size. And the way of the-diagnosis will be connected to the field of multiplicity. Considering multiplicity, the correct and accurte diagnostic ability for each lesion is definitely different from the ability for case diagnosis, especially in the present time EMR is carrying out. Reported incidence of multiplicity is around 18% in esophageal carcinoma cases, 10.7-18% in gastric early carcinoma cases and at least 12.8% in color-ectal carcinoma cases with the lesion of smaller than 0.5 cm. Classifying the lesions into three groups by its size as very small carcinoma whose size is smaller than 0.5 cm, early carcinoma larger than 0.5 cm and advanced carcinoma larger than lcm, the size of the lesion and elevation or depression are very important factors to make a correct diagnosis. As the size of lesion increases according to the order written above, shape of the lesion, depth of invasion and rigidity of the wall become more important. I would like to emphasize to diagnose a lesion in much earlier stage that the size of the lesion would be the first and largest subject and the elevation or depression would be the second.

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We have studied peroral micropancreatoscopy (PMPS) using ultrathin fiberscope with an external diameter of 0.75 mm, by which even the inside of an undilated pancreatic duct can be observed since 1988. PMPSs were carried out in 208 patients (35 cases of cancer, 44 of mucin producing tumors, 106 of chronic pancreatitis and others), and were successful in about 95%. PMPS findings of cancer were classified into five types : rough mucosal type, protruded type, erosive type, excavated type, and compressed type. But rough mucosal type was mostly seen. In mucin-producing tumor, a fish-egg-like appearance (caviar like appearance) was very characteristic findings, but it was sometimes difficult to distinguish benign disease from malignancy. Characteristic findings of chronic pancreatitis are stone, stenosis, protein plug, scar like appearance and redness. Pancreatoscopy has become indispensable to the diagnosis of pancreatic disease. Lately miniature ultrasonic probes for intracopor-eal scanning were newly developed. The diameter of these probes were 1.4 mm (CIVIS), 1.6 mm and 2.4 mm (OLYMPUS). Ultrasonic fre-quences were 30MHz (CIVIS), and 20MHz (OLYMPUS). These probes are applicable to the scanning of the main pancreatic duct without endoscopic sphincterotomy. Characteristic ultrasonograms were obtained in various pancreatic diseases. Although there were some problems which should be improved in the clinical use of PMPS and miniature ultrasonic probe, the use of intraductal endoscopy and intraductal ultrasonic scanning for the diagnosis of pancreatic disease will be applied to routine examination in the near future.

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Eighty-two cases with ischemic colitis were studied to reevaluate clinical features of this disease. The results were summarized as follows. 1) There were significant differences in the following items between 21 cases of the stricturing from and 61 cases of the transient form: the age, melena or hematochezia, associated disease suggestive of arteriosclerosis, and 1-h erythrocyte sedimentation rate within 5 days after the onset of symptoms. 2) The transient form of ischemic colitis and constipation prior to the onset of symptoms were more frequently present in young patients (20 under 45 years of age) than in older patients (16 over 71 years of age). 3) In 4 of 21 patients with stricturing form, radiographic examination revealed tubular narrowing and delayed healing of the lesion. 4) Recurrence of the disease was evident in 5 patients (6.1%). 5) Negative cultures of the bacteria including enterohemorrhagic Escherichia coli were considered to be necessary for the diagnosis of ischemic colitis. As ischemic lesions of the intestine other than ischemic colitis, there are obstructive colitis, ischemic enteritis, ischemic colitis caused by oral contraceptives, posttraumatic ischemic stricture, ischemic lesion due to phlebosclerosis, amyloidosis, collagen disease, radiation enteritis, Schoenlein-Henoch purpura, stercoral ulcer, and acute hemorrhagic ulcer of the rectum. In addition to above diseases, ischemic lesions may be caused by Eschrichia coli 0157: H7-associated colitis, non-pseudomembranous penicillin-related colitis, ulcerative colitis, and Crohn's disease. Pathogenesis as well as clinical features should be discussed for the classification of ischemic lesions of the intestine.

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Aim : Based on the findings that many gastric cancers develop in the stomach mucosa affected by severe and extensive chronic gastritis, and several studies have indicated that the serum pepsinogen levels, serve as a marker of chronic atrophic gastritis, so that, we aimed to establish the gastric cancer screening system using pepsinogens. Methods: In 1991, 4, 647, in 1992, 4, 758, and in 1993, 2, 242, in total 11, 647 (1, 742 persons in female; incidence 15%) company employees were given an annual periodic-health check-up that consists of an interview with regard to their general health conditions, a physical examination, an ECG, a chest X-ray and a blood sampling. The blood samples for routine laboratory test were taken after fasting and aliquot of the separated sera were individually stored at -20°C until serum pepsinogen levels were measured by Pepsinogen I and II Riabead Kits (Dainabot Co. Ltd, Japan). Results : As the result of their initial screening, out of 2, 456 subjects (21%) with a serum pepsinogen I levels of less than 70 μg/l and a pepsinogen I/II ratio less than 3.0, 1971 (17%) were selected for further investigation by endoscopy. This led to the detection of 17 subjects (incidence ; 0.15%) with gastric cancer, 13 were in the early stage (76%), and 8 subjects with adenoma (incidence ; 0.07%). Thus the cancer selection rate of this new screening method was found to be comparable, and in some ways superior to the traditonal barium X-ray screening. Moreover, this new screening method also has many advantages : (1) The method is easy and subjects experience no discomfort ; (2) No X-ray hazards are incurred and no side effects are experienced due to barium ingestion ; (3) The screening cost is less expensive (about a half the cost of barium X-ray screening) ; and (4) The procedure is quick and many serum samples can be measured at a same time. Conclusion : We have deviced a mass screening method that evaluate the serum pepsinogen levels to initially identify subjects with a high risk of a gastric cancer, and newly established the gastric cancer screening system, named "stomach dry dock".

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