The etiology and clinical course of intramural hematoma of the esophagus (IMH) after endoscopic injection sclerotherapy (EIS) were studied in 113 patients who were treated by EIS, including 15 patients with IMH (IMH group), and 98 patients without IMH (non-IMH group). The incidence of IMH was 13.3%, and not rare as complication after EIS. The mean infusion amount of sclerosant was 1.3 ml and mean size of IMH was 12.9 cm. Large hematoma was formated with a small amount of sclerosant. There were no difference between IMH group and non-IMH group in characteristics, blood platelet count, bleeding time, prothrombin time, and active partial thromboplastin time before EIS. Necrotic mass containing many dilated vessels in which thrombi were observed in the histological examination of IMH. In the X-ray pictures at EIS in IMH group, a ascending pooling picture of sclerosant was seen in 7 of 11 cases (63.7%), considered to be comparatively a characteristic X-ray finding of IMH group. The mechanism of IMH was considered that IMH was formed by injection of sclerosant into the part of loose submucosal tissue. The mean time up to disappearance of IMH was 8.1 days and minor complications such as chest pain and fever were observed. However, serious complications were not observed with conservative treatment. In this study, IMH showed a good clinical course and was considered a process of cure for esophageal varices by EIS. Therefore, it is suggested that IMH favors disappearance of esophageal varices.

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We performed clinicopathological investigation for 200 cases of heterotopic gastric mucosa in the upper esophagus, “so-called inlet patch”. The inlet patch was found in 200 of 2274 patients studied by endoscopic observation, a prevarence rate of 8.8%. The incidence of the inlet patch was more significantly higher in patient under the age 40 than over the age 70 (p<0.005). Small inlet patches under 4 mm in size were found more in patient over 70 than 40 (p<0.005). These data suppose that some of the inlet patch diminish or disappear in the age group over 70. Many cases with the inlet patch did not complain clinical symptoms related to the inlet patch. In 74 of the 200 cases with inlet patch, pathological examination was done. Microscopical findings of the inlet patch demonstrated significant inflammatory changes in 7 of the 74 cases. The gastric pyloric type epithelium was noted in 34 of the 74 cases and the gastric fundic epithelium, in 29 cases. These findings may support that clinical symptoms of the inlet patch possibly caused by acid secretion are not so common.

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Clinical study was done for 110 lesions of early gastric cancer in 103 cases which were treated endoscopically during past 13 years. And the results were as follows; 1) Indication for endoscopic resection was that histological type was differentiated adenocarcinoma, (2) diagnosis of depth of invasion was limited to mucosal layer, (3) cancer in hyperplastic polyps, type I or type IIa less than 2cm and type IIc not associated with ulceration less than 1cm. 2) Rate of complete resection was 43.8% in the former period (1981-1990), 77.2% in the latter period (1991-1993). 3) Rate of complete resection improved by using tripod type grasping forceps and unification of resection tecnique to EDSP method by Takekoshi. 4) It was difficult to resect completely type IIa more than 10mm and the lesion on the posterior wall of gastric body. 5) No recurrence was found in the cases resected completely. 6) Recurrent rate of the cases resected incompletely was 5.3%.

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We compared clinical features of 14 patients with stricture type of ischemic colitis and 96 patients with transient type of ischemic colitis. The results were summarized as follows. 1) Mean age of the patients with stricture type of ischemic colitis were significantly higher than those with transient type of ischemic colitis. 2) Patients with stricture type of ischemic colitis showed often atypical symptoms. Rate of patients without abdominal pain in stricture type was significantly more than that in transient type. 3) The vascular factors were found with significantly higher frequency in the patients with stricture type of ischemic colitis than in the patients with transient type of ischemic colitis. The intestinal factors were almost equally found in the patients with stricture type of ischemic colitis and in the patients with transient type of ischemic colitis. The results suggested that the intestinal factors play an essential role in the pathogenesis of ischemic colitis. 4) It seemed that circular lesions after two weeks or longitudinal lesions after four weeks develop into the stricture type of the disease. 5) It is possible that severe stenosis with ischemic colitis improve in a long time, and we must not undergo an operation in a hurry.

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Endscopic ultrasonography (EUS) was performed preoperatively in 79 patients with rectal cancer between April 1990 and August 1993. Among the 79 patients, twenty one patients who underwent radical operation with autonomic nerve preservation method were selected for this study under the EUS findings of tumor invasion limited within the proper muscle layer or less without lymph node metastasis. The depth of tumor invasion was correctly diagnosed in 18 of the 21 patients (86%). Three patients were diagnosed incorrectly with EUS because those tumor invaded beyond the proper muscle layer at the limited portion. Specificity of the diabnosis of lymph node metastasis by EUS was 91% (19 out of the 21 patients) . Of the two patients with false negative EUS determination, one showed microscopic lymph nodes metastasis and the other had distant lymph nodes metastasis. EUS is considered to be useful for the choice of function preserving operation for patients with rectal cancer.

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We gave a general term “Endoscopic Excision” to the resection of digestive mucosa under endoscope and to the extraction of submucosal tumor, both in digestive tracts. We have often experienced such cases in which it was most difficult or even impossible, depending on the sites of lesions, to apply the gastric endoscopic excision using conven-tional forward viewing 2-channel scope. To cope with these cases we developed a 45°forward oblique, 2-channel videoscope to achieve its experimental model GIF-2TK200. This scope is characterized in that with two 2.8 mm forceps channels, it has forceps lifter on the left forceps channel. Use of this scope has enable us to perform the excision of the lesions just below the cardia, which had not been applicable with the conventional forward viewing scope and, further, to facilitate the excision of lesions from the lesser curvatures in antrum and angulus to the lesser curvatures of upper body and to the posterior wall where we had extreme difficulty in excision. On the other hand, we succeeded in developing Type II, small-diameter W-W forceps with powerful holding that can be utilized for the 2.8 mm forceps channels of the scope. As in the case with the Type I, large-diameter W-W forceps, the above forceps have transversal claws all across the jaw and at the same time two vertical claws each on either side of the forceps tip, the opening width of which has been designed to be llmm, same with the Type I. It was confirmed that these forceps with equivalent holding power with the Type I can be useful in the endoscopic excision.

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A 73 year-old man with complaint of epigastric discomfort was admitted to Cancer Research Institute Hospital at Kanazawa on April 12, 1989 for precise examination and operation of an esophageal lesion. In the endoscopic exploration, a small superficially elevated lesion was found in the middle of esophagus. On May 30, 1989, We performed resection of intrathoracic esophagus by finger blunt dissection in due consideration of hypertension and old-age. A slightly elevated lesion of 0.9×0.5 cm in diameter of Type 0-IIa in the new endoscopic classification was observed in the middle portion of resected esophagus. Histological findings showed carcinoma in situ (ep) of squamous epithelium. However, cancer invasion to the level of muscularis mucosa (mm) was noted on the deeper cut of the cancer specimen. The diagnosis of basaloid-squamous carcinoma was established and neither lymphatic nor vessel involvement was found. This tumor was regarded as the smallest one of basaloidsquamous carcinoma of the esophagus reported in the literatures in Japan. The patient is alive without recurrence 4 years and 7 months after the operation. The prognosis for this carcinoma in such early stage is likely to be favorable compared to advanced stage cancer which is regarded as highly malignant.

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We presented a case of solitary Peutz-Jeghers type polyp of the stomach without familial inheritance. A 20-year-old male was admitted to our hospital because of general malaise. He showed neither mucocutaneous pigmentation nor inheritance of intestinal polyposis. An endoscopic examination was performed because of severe hypochromic anemia, and a large goose-egg-sized polypoid mass was found on the greater curvature of the stomach. X-ray study of the small intestine and barium enema showed no associated lesions. Biopsy specimens taken from the mass revealed benign hyperplasia of glandular epithelium. But, this gastric polyp was responsible for severe anemia with intermittent bleeding, and, therefore, excised. The excised specimen revealed a large, mulberry-like lobulated tumor measuring 8.5 × 5.5 × 3.0 cm. The histological examination disclosed a characteristic branching framework of muscle fibers derived from the muscularis mucosae and spreading between hyperplastic mucosal glands. No neoplastic tissue was present in it. Histologically, it showed typical features of Peutz-Jeghers type (hamartomatous) polyp. There have been two documents of a solitary gastric Peutz-Jeghers type polyp without both familial inheritance and mucocutaneous pigmentation. To our knowledge, there have been no reports on such a large and unique-shaped polyp including simple hyperplastic polyps.

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We report a case of a hyperplastic polyp which underwent malignant transformation, during radiographic and endoscopic follow-up for 13 years. The patient was a 75-year-old woman who had a 10-mm sized pedunculated polyp in the gastric body. Histologic examination revealed that the lesion was a hyperplastic polyp. There was no significant change in size and shape over the next 12 years. However, the polyp inceased to 19mm in size and developed uneven lobulation in the most recent 12month peroid. Endoscopy revealed a pedunculated polyp with a localized erosion, and biopsy showed a Group V lesion. Polypectomy was performed and the diagnosis of hyperpastic polyp with malignant transformation was confirmed histologically.

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A 38-year-old man, who comes from Okinawa prefecture, presented with severe proteinlosing gastroenteropathy. The upper gastrointestinal endoscopy showed remark-able widening of pyloric ring, thicking and sclerosis of the mucosa, irregular ulceration and pseudopolyps from the antrum to the third portion of the duodenum. He was diagnosed as strongyloidiasis by endoscopic duodenal mucosal biopsy, which showed Strongyloides stercoralis and its ova. S. stercoralis and ova were eliminated from the gastrointestinal tract and his clinical symptoms improved rapidly by a treatment with thiabendazole and ivermectin. After the treatment, the upper gastrointestinal endoscopy revealed recovery of pyloric ring, normal mucosa except ulcer scars and pseudopolyps from the antrum to the third portion of the duodenum.

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A 59-year-old woman was administered 300mg/day of ciprof loxacin for 7 days to treat common cold. After the medication, she suffered severe abdominal pain, diarrhea, and high fever. On admission, endoscopic findings of the sigmoid coin showed multiple plaques scattered over the mucosal surface. CD-check-Dl was positive in the stool. Judging from these findings, we diagnosed pseudomembranous colitis due to fluoro quinolone. She was medicated with vancomycin combined with prednisolone to treat hypoproteinemia. In this case, fluoroquinolone played an important role on developing pseudomembranous colitis, which was successfully treated.

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A 45-year-old bisexual man with acquired immunodef iciency syndrome (AIDS) visited our hospital because of general fatigue and loss of appetite. Endoscopic examination was performed because of epigastralgia and positive fecal occult blood. On this examination, multiple reddish-purple submucosal tumors ranged from 0.5-3 cm in diameter with irregular ulcers were observed at the pharynx, gastric body and cardia. Histlogical examination appeared gastric Kaposi's sarcoma. This paper reports a case of gastric Kaposi's sarcoma associated with AIDS, which is a very rare disease in Japan.

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We performed endoscopic transpapillary catheterization into the gallbladder (ETCG) in a case of the impacted stone of the cholecystic duct. A double contrast method was carried out after 480ml of bile was aspirated from the gallbladder through the transpapillary catheter. This new modality exactly identified multiple small stones in the gallbladder that was thought to be undetectable by ERCP, CT and sonoscanning. The gallbladder was too much distended to resect by laparoscopic cholecystectomy (Lapa-C). Drainage of the gallbladder by ETCG decreased its size, and then Lapa-C could be performed safely. We consider that ETCG could be applied for the diagnostic and therapeutic methods in patients with impacted stones in the gallbladder neck.

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A 77-year-old woman with complaints of general fatigue, ascites and high level of serum transaminases admitted to our hospital on suspicion of acute hepatitis. Hepatitis virus markers were negative. Because of hypergammaglobulinemia (IgG 3850mg/dl) and positive LE cell phenomenon, the diagnosis was made as autoimmune hepatitis and the corticosteroid therapy was started. One month later, jaundice and ascites were well controlled and serum transaminases were recovered to normal level. Laparoscopy was performed three months after the onset. Liver surface was uneven, and protruded region showed reddish patchy or nodular formation. Grooving depressions with localized reddish markings were also found. Histological findings were compatible with the late stage of severe acute hepatitis. Opportunity of laparoscopic observation for such an aged patient with autoimmune hapatitis showing acute onset was thought to be rare.

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Since October 1992, endoscopic variceal ligation (EVL) has been used as a treatment of esophageal or gastric varices in 11 patients. The selected patients had liver cirrhosis accompanied by varices with positive red color sign. These patients consisted of 4 cases in stage A, 5 cases in stage B and 2 cases in stage C according to Child's classification. EVL was performed as supplementary therapy after endoscopic injection sclerotherapy (EIS) (4 cases) and replacement therapy because EIS was impossible due to hepatic failure (2 cases). EVL was also done for recurrent varices with atypical red color sign as an initial treatment (3 cases) and for the rupture of esophageal varices as an emergent therapy (2 cases). Varices had disappeared and red color sign became negative in whole cases. No recurrent varices with red color sign were demonstrated after EVL during the period of follow-up study (average 217.5 ± 79.8 days). No major complications were found during and after EVL.

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We experienced five cases of spontaneous rupture of the esophagus. The patients were all males and the age ranged from 44 to 62 years (mean, 53.2 years). Symptoms began with vomiting in all patients. Four of them complained of both chest and abdominal pain with hematemesis (2 cases) or dyspnea (2 cases). Diagnosis was made based on the findings of endoscopy (2 cases), both endoscopy and CT (1 case), and esophagogram (2 cases). Length of the rupture was 2.8 cm in average. The left wall of the lower esophagus was ruptured in 4 cases, and in 1 of them both left and right walls were ruptured. Surgical operation was performed in all patients, and 4 of them survived. Emergent endoscopic examination performed in 2 cases within lhr or 7hrs after the onset of the symptoms, revealed longitudinal linear tears surrounded by the mucosa with no inflammatory change and the esophageal lumen was collapsed. These endoscopic findings enabled us to make an early diagnosis. However, the tear just at the esophagogastric junction observed in 1 case quite resembled the endoscopic findings of Mallory-Weiss syndrome. Endoscopy was performed 19 days after the onset in 1 case, and an oval rupture site surrounded by scared tissues was observed. In 2 of the 3 cases who underwent endoscopy, subcutaneous emphysema developed, but there was no serious complication. Emergent endoscopy is considered to be performed safely and very useful for early diagnosis of spontaneous rupture of the esophagus if avoids too much inflation.

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From April 1991, we have performed endoscopic gastric mucosal resection and closure of mucosal defect with metal clips on 10 cases of early gastric carcinoma. Markings were placed at surgical margin (5-10mm) with satisfactory distance from the lesion, and the marked points were traced by needle-shaped electric cautery to perform resection in quasi-circular form. After snaring, the mucosa of the lesion was extensively resected. Then, to prevent hemorrhage, perforation and formation of artificial ulcer, mucosal defect was closed by metal clips. There was no bleeding postoperatively as well as intraoperatively, and the formation of artificial ulcer was avoided in 9 cases. The results of histopathological study of the surgical margins were as follows : The shortest distance of surgical margin 3-6mm ; 4.5±1.0 mm in average; The number of normal ducts 17-36 ; 27.0 ± 6.0 in average. This suggests that complete resection was performed in all cases with free surgical margin. Endoscopic follow-up was performed for 2 years 6 months at the longest. No recurrence of carcinoma was found. In conclusion, these results suggest that this method has been effective for complete resection of early gastric carcinoma and that it has been fairly effective for the prevention of complications.

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