In order to characterize gastric mucosal lesion in patients with portal hypertension (which is called portal hypertensive gastropathy; PHG), portohepatic hemodynamics were studied in cirrhotic patients. Hepatic venous pressure gradient which reflects portal vein pressure was significantly higher in severe gastropathy group than in without gastropathy group (p <0.05) and in mild gastropathy group (p <0.05). Azygos blood flow which thought to be an index of ascending porto-systemic shunt was not different in these groups. H/L ratio determined by T1-201 chloride per-rectal administration which thought to be an index of descending portosystemic shunt was significantly higher in severe gastropathy group than in mild gastropathy group (p<0.05), but the difference between severe gastropathy group and without gastropathy group was not significant. These observations support the view that portal hypertensive gastropathy depends not only on portal vein pressure but also on the type of collateral vein route.

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Twenty nine patients with bullous disease (pemphigus vulgaris;14 cases, bullous pemphigoid;13 cases, pemphigus f oliaceus; 2 cases) were examined endoscopically for esophageal lesions. Only 30 cases of the esophageal lesions in bullous disease has been reported, however we found the lesions in 15 patients (52%) endoscopically. Eleven patients (73%) had only bullae in the esophagus, 3 patients (20%) had exfoliative esophagitis and 1 patient (7%) vomited esophageal mucosa. Esophageal lesions in pemphigus vulgaris (10 cases; 71%) is more frequent than that in bullous pemphigoid (5 cases; 38%) and pemphigus f oliaceus (0 case). Incidence of skin lesion was lower tendency of activity in cases with exf oliative esophagitis. In most of reported cases, patients were diagnosed esophageal lesion while being in complete clinical remission, it is indicated that there is a negative correlation between esophageal lesions and activity of skin lesions. Patients with bullous disease accompanied with high incidence of oral lesions during course of it. Steroids were effective for therapy of esophageal involvement. Thirty other reported cases were also reviewed.

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To investigate whether allergic mechanism was related to the concerned in complica-tions of endoscopic injection sclerotherapy (EIS), we measured eosinocyte, serum IgE, fibrinogen and D-dimer in 23 patients undergoing EIS by the method of intra and paravar-iceal injection using 1% Aethoxysklerol (AS). Eosinocyte, serum IgE, and D-dimer in-creased after EIS. There was no significant correlation among the total volume of 1 % AS, the peak of eosinocyte and serum IgE. Patients with eosinophilia after EIS had significant increase in the cases of pleural effusion, but there was no correlation between serum IgE and development of pleural effusion. Eosinocyte began to increase rapidly 3-4 days before the development of pleural effusion. Serum IgE showed a tendency to increase step by step from one week before the appearance of pleural effusion. There was no significant correlation between fever and increase of eosinocyte or serum IgE. In patients with pleural effusion, beacuse serum IgE increase earlier than eosinocyte and D-dimer, it was thought that the development of pleural effusion was related to the allergic mechanism in addition to the direct effect of 1% AS injected into the paravariceal wall. In conclusion, allergic mechanism was suspected to contribute in some part to the complications from EIS.

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A transparent-tip-hood-fitted zooming magnifying electronic endoscopy (Olympus, GIF-200Z) was estimated basically and clinically whether to be proper for screeing endo-scopic examination or not. GIF-200Z had a bigger tip (11.9 mm), so it was difficult to insert into the esophagus when estimated by our new method of measuring the ratio of the short axis to long one of distorted outlines of a transparent tip-hood at insetion. Although it had a small bending up-angle (180 degree), the observation of the angulus was not so disturbed as expected. In our basic study, GIF-200Z has a resolution above 48.3μ, then, it was thought to be sufficient for observing the fine gastric mucosal pattern. But 12.8-36.3% of magnifying endoscopic pictures were not proper for the estimation of fine mucosal patern because of cardiac pulsation, gastric vermiculation, breathing, and gastric juice. A transparent tip-hood was useful for conquering their factors disturbing the stable magnifying endoscopic observation. When iodine protassium iodine solution was sprayed in the esophagus, the time required in endoscopic examination using the transparent tip-hood was shorter than that without it. Then a transparent tip-hood is thought to be very useful for magnifying observation of the esophagus. Ectopic gastric mucosa and solitary venous dilatations of upper esophagus, and mild ref lux esophagitis could be found more frequently. The duodenal ulcer scar just beyond the pyloric ring could be found more frequently. It is concluded that transparent-tip-hood-fitted GIF-200Z is an epochal endoscopy because it can be used for screening and magnifying observation at the same time, and that it will be expected to contribute the development of reserch for the epidemiology and the etiology of digestive diseases.

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Incidence of ectopic sebaceous gland in the esophagus is very rare and only ten cases discovered by endoscopy and biopsy have been reported. We report the 2 cases (case 1; 65 -year-old man, case 2; 76-year-old man) of the asymptomatic sebaceous glands in the esophagus diagnosed by histological examination of endoscopic biopsies. Small yellowish elevated lesion (2-5mm in diameter) resembling gastric xanthoma was detected by upper gastrointestinal endoscopy at the middle esophagus in both cases. Biopsy specimens revealed a normal squamous esophageal mucosa with sebaceous glands in these two cases. Origin of the sebaceous gland in the esophagus is still unknown whether it develop from fetal abnormality or metaplastic change. Furthre investigations are necessary to solve this debate.

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A 64-year-man was admitted to our hospital complaining of odynophagia and retros-ternal pain. Chest X-ray film showed mediastinal emphysema and spontaneous esophageal rupture was suspected. Urgent endoscopy revealed the exsistence of remarkable sub-mucosal hematomas extending from the upper part of the esophagus to the middle part followed by exfoliative mucosa and ulcers toward the anal side. The diagnosis of ex-foliative esophagitis was made and conservative therapy was selected. His symptoms disappeared 5 days later. Esophageal barium-meal examination on the 17th hospital-day showed no leakage of barium into mediastinum and diverticulum-like barium retension in Ce, and band-like longitudinal recesses in lu to Im corresponding to the exf oliative lesions. Second endoscopy on the 20th hospital-day showed diverticulum-like finding and longitudi-nal ulcer scars similar to those arised after endoscopic sclerotherapy for esophageal varices. His clinical course was uneventful. This case suggested that exfoliative eso-phagitis might develop from submucosal hematomas to mucosal exfoliations, resulting in ulcers, and also showed that the exfoliation might progress to oral direction. Moreover, this case suggested that perforation might occur in exf oliative esophagitis if fragility of esophageal wall preexsisted. Our conclusion is that exfoliative esophagitis (traumatic type) is not an intermediate type between laceration (Malloy-Weiss syndrome) and sponta-neous esophageal rupture, but should be the other clinical entity because of the difference on the cause and pathological process.

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A 55-year-old woman with a chief comlaint of epigastric discomfort was examined at our outpatient clinic on July 3, 1992. X-ray examination of the stomach and endoscopy revealed four submucosal tumor-like lesions : a 15mm and a 7mm lesions in the midbody towards the greater curvature aspect of the stomach. a 9mm lesion in the midbody towards the lesser curvature, and a 5mm lesion in the fundus of the stomach. During endoscopy, biopsy was taken from the larger lesion in the midbody of the greater curvature, and because gastric malignant lymphoma was suspected, the patient was admitted to our department on July 24. When endoscopic ultrasonography was performed, all of the lesions were found to lie in the mucosal and submucosal layers of the stomach. They had sharply defined boundary, their interior echo was homogeneous, and their echo level was the same as the proper muscle layer. The lesions were thought to represent gastric malignant lymphoma. In addition to the four lesions confirmed endoscopically, two lesions exhibiting the same echo level were visualized in the midbody of the greater curvature and the midbody of the lesser curvature. Based on the above, a diagnosis of multifocal primary malignant lymphoma of the stomach was made (6 lesions) extending from the middle of the body to the fundus of the stomach. When surgery was performed on September 18, seven lesions ranging from the midbody to the fundus were found. Histologically, it was primary early gastric malignant lymphomas, showing diffuse, medium-sized cell type and its invasion was limited to the submucosa.

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Two cases of intraluminal duodenal protrusion were reported. Case 1; A 55-year-old female was referred to Senboku Kumiai General Hospital for the further evaluation of an abnormality of the duodenum detected in mass survey. Endoscopic examination revealed an elongated, protruding lesion at the upper part of the second portion of the duodenum. Endoscopic polypectomy was performed. Histology demonstrated the lesion consisting of normal mucosa, muscular mucosae and submucosa. Fatty tissue, dilated blood and lymph vessels were demonstrated in the submucosa. Proliferation of Brunner's gland was prominent at the tip of the protrusion. The additional case which showed endoscopic findings at the duodenal bulb similar to case 1 was also described.

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We reported a case with Cowden's disease who was 41 year-old female in association with gastrointestinal polyposis and colon cancer. X-ray and endoscopic examinations revealed multiple small polyps in the esophagus, stomach and rectosigmoid colon. The histological findings of these polyps showed hyperplastic polyp. We also found a pedun-culated polyp which was 15mm in diameter in the mid-sigmoid colon. Histological findings of the polypectomized pedunculated polyp was well differenciated adenocarcinoma. Cowden's disease is a rare diease. Based on review of literature, 38 cases have been previously reported in Japan. And this is the 3rd case of Cowden's disease accompanied by colon cancer in Japan.

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A 28 year-old female admitted to our hospital on January 13, 1992 with chief com-plaints of bloody stool and right lower quadrant pain. On admission, a goose-egg sized tumor was palpated in the right lower quadrant with slight tenderness. Next day the tumor moved to the right upper quadrant. Ultrasonography showed a low echoic mass with multiple concentric ring sign. Barium enema revealed coil spring appearance in the transverse colon. After reduction by hand, a regular and round defect was found in the fundus of the cecum. The dianosis of intussusception caused by a ileocecal tumor was made. Colonoscopic examination revealed a polypoid lesion with erosion and reddness in the cecum. Computed tomography and magnetic resonance image demonstrated a cystic lesion in the cecum. Clinically, a mucinous cystadenoma of the appendix was diagnosed, and the appendectomy was performed. Macroscopicaly, the tumor was remarkably swollen appendix containing gelatinous substance and mucin. It was pathologically diagnosed as mucinous cystadenoma of the appendix.

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We presented a case of liver injury induced by Kinshigan, oriental herb drug. A 54 year old female took Kinshigan for 8 months before admission. After taking 60 bits of the drug for 7 months, she started to take double dose (120bits) and had severe general malaise and icterus. On admission, total bilirubin, s-GOT and s-GPT were increased markedly. The virus antibodies, the autoantibodies and lymphcyte stimulation test by Kinshigan were all negative. Hapatic encephalopathy did not developed but prothrombin time showed 56.2% at 3rd week after admission. 12 weeks after admission, she recovered from liver dysfunction. Laparoscopy revealed mild liver atrophy and severe hepatic necrosis. Histological findings of biopsy specimen showed multilobular necrosis, degeneration, portal cellular infiltration. In this case, severe acute hepatitis were supposed to be induced by herb drug Kinshigan.

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We attempted the combination method which was simultaneous use of endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL). First of all, EIS using 1% Aethoxysklerol was performed on the oral side of the esophagus by means of endo-scopic ballon inflation and EVL was subsequently done on the anal side of the esophagus. Since the treatment with new method was successfully completed in 2 cases in a short time, we conclude that this method could be a useful therapy for esophageal varices.

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We have been reporting on various techniques of endoscopic surgery using a transpar-ent hood attached to the tip of a scope. Recently, we have treated a total of 18 cases [15 esophageal stenosis, 3 pyloric stenosis] and have obtained favorable results in its use for the treatment of stenosis of the upper gastrointestinal tract. Regarding the success of endoscopic surgery for the stenosis, it is important to make detailed observations of lesions and to perform adequate treatment on these areas. However, when the tip of the scope draws excessively near the site of the stenosis in order to observe it in detail, it is difficult or impossible to observe the lesion, because the lens of the scope comes into contact with the lesion, thus, obscuring the view. On the other hand when the scope parts the site of the stenosis, it is difficult to perform fine endoscopic surgery. Using the transparent hood, even when drawing nearer, a constant distance is kept between the lesion and the tip of the scope, and detailed observation of the lesion is possible. Moreover, it is possible to fix the tip of the transparent hood at the intended site, thus, adequate treatment can be performed safely. This transparent hood can be applied not only for the treatment of esophageal stenosis but also for that of pyloric stenosis.

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