1988年10月から1993年1月までに当科で初回治療後6カ月以上経過観察した食道静脈瘤硬化療法(EIS)39症例と,クリップ法(EVL-c)とEIS併用療法を施行した31例の再発期間を比較検討した.また再発に関与する因子に関し多変量解析を用いて検討した.EVL-cとEISの併用はEIS単独と比較し,硬化剤の総使用量は32.3mlと減少し,治療期間も4.69週と短かった.静脈瘤の再発は,総使用硬化剤量,総使用クリップ数,肝機能,肝細胞癌の合併,飲酒量とは相関せずEVL-cを併用した場合のみ有意(p<0.01)に再発した.治療1週毎の硬化剤量が7m1以下で,クリップ1個当りの硬化剤量が5ml以上の場合,非再発期間は延長した.EVL-cとEIS併用治療後の超音波内視鏡検査にて食道粘膜が2mm前後であり,EIS単独治療後の5mm前後と較べ粘膜層の肥厚は少なかった.また病理組織所見で食道粘膜層の線維化が弱かった.EVL-cとEIS併用療法は,総使用硬化剤の減量や治癒期間の短縮などの利点があるが,EIS単独に較べ非再発期間が短かった.EVL-cとEIS併用療法では,F1RC(-)で治療終了とせず,長時間血管外注入を持続するほうが非再発期間を延長すると考えられた.

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　エピネフリンを胃潰瘍瘢痕部に撒布するpharmacoendoscopyの色調変化を,客観的に評価するため,画像解析を用いた粘膜血液量より,その経時的変化を検討した.pharmacoendoscopy後の色調変化は,P_R(発赤が残存),P_W(完全に蒼白化)の2群に分類した.エピネフリン撒布による赤色瘢痕部の粘膜血液量の減少率は,白色瘢痕部,健常粘膜部と比較し有意に低値であった.pharmacoendoscopy所見とエピネフリン撒布後の粘膜血液量の変化を比較すると,撒布直後よりP_R群の粘膜血液量の減少率はP_Wならびに健常粘膜部に比べ低値であった.また,撒布前のP_R群の健常粘膜部に対する粘膜血液量は健常粘膜の1.2倍であったものが撒布後には約1.4倍と増加していた.しかし,Pw群では,健常粘膜に対する瘢痕部の粘膜血液量の明かな変化は認められなかった.pharmacoendoscopyによる色調変化は,画像解析により定量化が可能で,その変化は,粘膜血液量に相関することが示唆された.

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　地固め法の新しい手技として,レーザー地固め法を11例に施行し,従来のAS地固め法と比較検討した.地固め法はEO・AS併用法を基本として静脈瘤を完全消失させ,さらにASにて下部食道を線維化させる手技である.このAS注入による線維化法をレーザー照射に変えたのがレーザー地固め法である.レーザー照射は出力13W,パルス時間1秒以内とした.11例の治療回数は1-6回(平均3.4回)で1回の総熱量は828～6,306ジュール(平均2,250ジュール)であった.レーザー照射部位は血栓化静脈瘤と正常食道粘膜とし,下部食道に全周性に照射した.AS地固め法と比較し,治療手技が簡便であり,浅く均一な潰瘍形成ができるため食道狭窄は来さず,食道壁の十分な線維化が得られた.レーザー地固め法の予後は,観察期間が最長17カ月と短期間であるが再発はない.以上のように,レーザー地固め法は安全でかつ再発防止上有用な方法である.

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　症例は74歳男性.検診の胸部レ線にて異常を指摘されて初診.上部消化管内視鏡にて食道進行癌と診断され,他の画像診断にて肝肺に転移性腫瘍を認めた.Cisplatin 80mg,Vindesine 3mgのPV療法および油性Bleomycin30mgの経口投与を施行した.6クール終了した時点で転移巣は指摘できず,食道原発巣も瘢痕化していた.多臓器への転移を伴いstage IVの予後不良と考えられた食道癌に対して化学療法が著効を示した稀な症例と考えられた.

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　症例は65歳,女性.下腿浮腫と体重減少を主訴として受診し,血清総蛋白4.0g/dl,ヘモグロビン6.5g/dlと著明な低蛋白血症と貧血を認めた.胃X線・内視鏡検査・生検にて絨毛状増殖を示す5型進行胃癌と診断した.α₁-アンチトリプシン・クリアランス試験や塩化インジウムシンチグラフィーにて,腫瘍からの蛋白漏出を示唆する所見を得た.胃全摘後には,蛋白漏出の所見は消失し,低蛋白血症および貧血の改善をみた.

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　症例は55歳,男性.腹部膨満感を主訴として受診.腹部単純X線写真で左上腹部に砂粒状を呈する著明な石灰化陰影を認めた.腹部超音波およびCT検査にて胃壁内の石灰化像と判明し,上部消化管X線および内視鏡検査で,石灰化を伴ったBorrmann4型胃癌と診断した.生検では印環細胞癌が,剖検では膠様腺癌が主体を占めていた.腹部単純X線上石灰化像を認めた胃癌の本邦報告例は自験例も含めて64例である.その特徴は,若年女性に多く,肉眼型はBorrmann3型と4型が多くみられる.組織型は膠様腺癌,印環細胞癌が多く一般的に予後不良である.

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　症例は80歳,男性.胃潰瘍にて経過観察されていたが,1993年1月の胃内視鏡検査で胃体下部後壁に潰瘍性病変を2カ所認め,生検ではいずれも悪性リンパ腫の所見であった.約2カ月後には2カ所の潰瘍は瘢痕化したが胃角後壁に新たなびらんの出現を認め,生検にて悪性リンパ腫の所見を得た.Diffuse large cell typeの胃悪性リンパ腫と診断し,胃全摘術を施行した.切除標本では胃体下部後壁の2カ所の潰瘍性病変はU1-IIsの疲痕像を呈し,腫瘍細胞は認められなかった.胃角後壁のびらん部には0.2×0.3cmの範囲で粘膜固有層に限局する微小悪性リンパ腫を残すのみであった.胃悪性リンパ腫は悪性サイクルを示し,その過程において潰瘍形成に伴う腫瘍細胞の脱落をきたし,腫瘍の自然退縮,進展を繰り返す経過をとることがあるので診断及び治療に留意が必要と思われた.

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　症例は61歳,女性.心窩部痛を主訴に,胃内視鏡検査を施行した.胃体下部から胃角の小蛮を中心に境界不明瞭な退色調粘膜を呈し,その周辺には多発性の発赤,びらんを伴っていた.生検組織検査にて形質細胞腫と診断し,胃全摘術を施行した.切除標本では,胃体部から幽門部にかけて広範囲に異型を示す形質細胞の浸潤を認めた.これらの細胞はいずれも粘膜内に限局しており,免疫組織染色ではIgM,xにmonoclonalに陽性であった.

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　十二指腸球部の異所性胃粘膜病変を認め,コンゴーレッド法により酸分泌能を確認し得た2例を報告した.症例1は50歳の男性で,人間ドツク時の胃X線検査,症例2は46歳の男性で,胆摘術前の内視鏡検査にて発見された.われわれは,この酸分泌能を有する異所性胃粘膜の,自験例2例を含む7例の内視鏡的特徴を文献的に検討した.この特徴は,十二指腸球部口側の穎粒状多発隆起で,十二指腸球部内に随伴病変を伴わないことであった.

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　症例は21歳男性.低酸素脳症で加療中,暗赤色の下血を生じた.内視鏡検査により,直腸には,出血を伴う半周性の潰瘍を認め,回腸末端に下掘れ傾向の強い小潰瘍の多発を認めた.内視鏡所見,病理組織診等から出血性直腸潰瘍に,単純性小腸潰瘍を合併したものと考えた.Heaterprobe,エタノール局注を行ない出血は軽快し,その後栄養療法等により潰瘍の治癒を見た.本例は単純性小腸潰瘍が,出血性直腸潰瘍と同じくストレスにより発症する可能性を示唆するものと考えた.また,下部消化管出血の急性期においても,診断及び治療のため可能な限り回腸末端の観察をすることが必要であると考えられた.

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症例は66歳男性で左側腹部痛を主訴に来院した.大腸内視鏡検査,注腸造影,腹部CTにてS状結腸痩,腹腔内膿瘍と診断し手術を施行した.術中,肉眼的にはS状結腸の痩孔部の確認は困難であった.しかし,内視鏡にて痩孔部を確認し虫垂炎による虫垂結腸痩と診断し,病理組織学的に確認された.虫垂結腸痩の診断法として注腸造影が有用とされてきたが,本症例は大腸内視鏡検査が診断の有力な手掛かりとなった.

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症例は76歳男性.便潜血反応陽性の精査で大腸鏡検査施行.回腸ポリープを指摘され来院.当院で施行した大腸鏡検査では小腸ポリープを先進とする腸重積状態が回盲部で観察された.注腸造影検査では回盲弁より約30cmの回腸に亜有茎性ポリープが描出された.病理組織学的所見では,大きさ35×25×19mmの表面分葉状のポリープで中等度異型を伴う腺管絨毛腺腫であった.回腸腺腫は比較的まれであり貴重な一例と考えられたので報告した.

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症例は70歳,男性.平成3年7月9日より発熱,下痢,左下腹部痛が出現し,当院受診.大腸内視鏡検査にて,上行結腸に白色調で表面平滑な4×6×5mmの有茎性ポリープを認め,ポリペクトミーを施行した.組織学的には炎症細胞の浸潤を伴う線維芽細胞の増生がみられ,Inflammatory fibroid polypと診断した.大腸に発生したInflammatory fibroid polypの報告は稀であり,本邦では自験例を含めて8例であった.

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尋常性天疱瘡の経過中に潰瘍性大腸炎の発症をみた1例を経験した.症例は,47歳,女性.口腔内びらんで発症後,胸腹部水疱および下肢結節性紅斑が出現.水疱部生検像,螢光抗体直接法により,尋常性天疱瘡と診断した.下痢,便潜血反応陽性が続き,注腸造影,大腸内視鏡検査により潰瘍性大腸炎と診断した.抗表皮細胞間抗体による自己免疫疾患である尋常性天疱瘡に,やはり自己免疫の関与が考えられている潰瘍性大腸炎を合併した稀な1例を報告した.

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症例は43歳男性のアルコール性肝硬変.食道静脈瘤破裂を主訴に入院.待期的硬化療法により食道静脈瘤出血は止血したが,その後portal hypertensive gastropathy(PHG)からの顕性出血を生じ保存的治療では止血困難であった.緊急で経頸静脈的肝内門脈大循環短絡術(TIPS)を行ったところ劇的に止血し,その後内視鏡検査によりPHGの改善を認めた.TIPSはPHGからの出血の治療に有用なことが示唆された.

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　早期食道癌に対する根治術として内視鏡的粘膜切除術を施行する際に,その適応の可否を判定するためにも,術前に粘膜癌および粘膜下層癌の正確な深達度診断を行うことが重要であり,そのために細径超音波プローブの有用性が注目されている.われわれは,スコープ壁にバルーンを外付けすることにより,脱気水充満下に良好な超音波像を獲得できる簡便かつ確実な方法を考案したので,本法の有用性についてラジアル型20MHz試作細径プローブ(オリンパス)の使用経験を含めて報告する.

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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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