Endoscopic examination was performed in 215 patients who were 65 years or older.They conLsisted of 71 senile dernentia of Alzheimer type(SDAT) and 144 cerebrovasculardementia(VD). Results were as follows; 1) Endoscopy was performed for anemia(32.1%), which was the mLaior reason, followed by for U.G.I series(19.2%), loss of apPetite(16.3%)and abdominal pain(15.8%). 2) Lesions of the upper digestive tract were detected in 68 patients (31.6%), of whom 24(11.2%)had peptic ulcer, 18 had(8.4%)gastric cencer and 8 (3.7%) had AGML. 3) In the relationship between dementia and gastric diseases, lesions of the upperdigestive tract such as carcinoma of the stomach and peptic ulcer were found more oftenin the VD patients than in the SDAT patients or non-dementia patients. The VD patientswere also found to have lower serum pepsinogen I and I/II ratios than the SDAT or nondementia patients. Results suggested that atrophy of gastric mucous membrane occurredin the VD patients du.e to arteriosclerosis.

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We examined endoscopic findings by POPS (Peroral Pancreatoscopy) for 24 patientssuffering from chronic panceratitis, 18 with advanced pancreatitis (ADP) and 6 withmoderate pancreatitis (MOP) . Abnorrnal findings of the main pancreatic duct mucosa wereobtained in 220f the 24 cases (91.7%), 4 of 6 MOP cases (66.7%) and all of 18 ADP cases (100%) . Of the 4 positive, MOP cases, rough mucosa was demonstrated in 3 (75%), redness in 2 (50%), scar in 2 (50%) and granular mucosa in 1 (25%) . The 18 ADP cases werecharacterized by rough mucosa in 13 (72.2%), edematous mucosa in 11 (61.1%), redness in7 (38.9%), scar in 6 (33.3%), granular mucosa in 4 (22.2%) and nodu.lar change in 2 (11.1%) .As regards intraductal abnormal findings of the main pancreatic duct, significant floatingsubstances were found in 20f 6 MAP cases (33.3%) and in all of 18 ADP cases (100%) . Pancreatolitiasis was also revealed in 10 of 18 ADP cases (55.6%) . By POPS, the numbefsof abnorrnalities of the rnain pancreatic duct rnucosa, intraductal floating substances and appearance of pancreatalitiasis in chronic pancreatitis were increased, parallel to pancreatography. From these results, we concluded that POPS is a useful methods for thediagnosis of chronic pancreatitis.

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Pathological findings related to GVHD were observed by endoscopic examination inpatents with hematological disorders after allogeneic bane marrow transpiantatian. Twopatients clinically manifested intestinal GVHD such as diarrhea and abdominal cramps, while four had no such syrnptoms. Endoscopic findings in, patients with or without GVHDsymptoms who showed positive pathological GVHD were as follows. Edema, erythema, erosion, lymphoid hyperplasia in both the duodenum and dower intestine, and an aphthoidulcer in the lower intestine were observed. Pathological findings detected by endoscopicbiopsy are important for the diagnosis of intestinal GVHD even if the patients havingundergone allogeneic bone marrow transplantation, did not show clinical intestinal GVHDand showed almost normal or slight change on endoscopic morphological findings.

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Over the last 10 years, 100 patients with esophagogastric varices have been treated by endoscopic injection sclerotherapy(EIS)in our medical department. We analyzed 87 cases here in which endoscopic varicealography were performed during the first endoscopic intravariceal scleratherapy. We classified the endoscopic varicealographic findings into four groups; I : common type, II:instantly disappering type, III:interrupted type, IV:retrograde disappering type, and analysed the 87 cases according to these four criteria. Seventy four patients (85.1%) were classified as type I, 5patients (5.7%)as type II, 5patients(5.7%)as type III, and 3 patients(3.4%)as type IV. The therapeutic effectiveness of the EIS was studied fer each of these four EVIS groups. The effectiveness for type I was 93.2%and for type IV was 66.6%. However, the effectiveness for the type II and III was low in all cases. This study suggests that varicealography is an important technique for performing endoscopic sclerotherapy. Our classification on image aspects gives us the possibility of knowing the dynamics of local flood circulation of the varices, which is an important factor in predicting the therapeutic effectiveness of sclerotherapy.

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Balloon-Qcclu.ded Retrograde Transvenous Obliteration(B-RTo)was performed infour patients with solitary gastric varices from March 1993 to November 1994, and preand post-B-RTE course of the disease was examined by ultrasonic miniture probe(UMP).Pre-B-RTO UMP revealed non-echo luminal image, but UMP showed the dotted high echoarea in varices immediately after B-RTE. After temporary appearance of the dotted highecho area, non-echo luminal images were observed while the luminal shape remainedunchanged ar the luminal size reduced slightly:Then, gastric varices disappeared in allpatients. Experimentally, 5%EO was administred in vein of white rabbits'ear, andultrasonic and histopathological changes were examined at intervals. In blood vesselsshowing a non-echo luminal images, a doted high echo image appeared in the non-echolumen immediately after 5%EO infusion, which increased one minute after. Almostsimilar ultrasonic findings remained u.p to day 3 after the injection. Histopathologicalexamination revealed that endothelical cells of the veins disappeared immediately after 5%EO infusion, and that clots were noted as if to fill up the vessels. Histopathological findingsat minutes 15 after release of avascularization included edema around the extravasculer wall. At hour 1, fibrin precipitated and fibroblasts appeared in the vascular wall. At hour3, the fibrin precipitation and slightly increased fibroblasts in the vessels were still present.These results of the clinical and basic studies suggested that the dotted high echo appearingafter administration of 5%EO reflected the changes resulting from endothelialdisordersand associated occurrence of intravascular clots. It remained unknown what kinds ofhistopatholagical changes yieled the UMP finding that the nan-echo luminal imagesappeared following the dotted high echoin the gastric varices.

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When we use an ultrasonic micro-probe for lesions in the upper gastro intestinal tract, there may be difficultiy to fill de-aerated water. We apply an optical laser balloon(M&MCo. Ltd)to deal with the difficulties. We attach the optical laser balloon on the tip ofan endoscope and fill de-aerated water in the optical laser balloon via the forceps channelof the endascope. Ta perform endosonagraphy, eve introduced an ultrasonic mitre-probevia the forceps channel of the endoscope. By means of this device, we do not have difficultyto fill water at any places in the upper gastro intestinal tract. we could ebtain theendosbnogram of the lesion with ease, because we could keep an optimal angle and distancebetween the ultrasonic micro-probe and the lesion. Furthermore, patients did not complainapain due to reflex of the de-aerated water during examination. This device will makean innovation in the endosonography by u.tilizing the ultrasonoc micro-probe.

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Helicobacter pylori (HP)infection was assessed in the residual stomach after distalgastrectomy due to gastric cancer, in comparison with unoperated whole stomach. HP wasdetected by Urease test from the gastric mucosa specimens of anastomotic area and cardiain residual stomach and from antral mucosa and angle in unoperated stomach. HPinfection was subsequently confirmed by culture in 5kirrow media, compared according toendoscopic and histopathological findings. HP infection rates were 75%(27/36)forresidual stomach cases and 59.6%(109/171)for whole stomach cases(P=0.08). Nostatistically significant correlations were observed between HP infection and sex, postoperative years and histological findings or background disease, while higher infection rateof HP was observed in the patietnts who were operated because of early gastric cancer.HP infection rate vvas statistically higher in the residual stomach with superficial gastritis(88.8%)than that with atrophic gastritis(33%). The resu.lts suggest that HP infectionseems to have some role in developing superficial gastritis in the residual stomach.

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We experienced a rare case of a primary adenocarcinoma of the esophagus of 29-year-old-male. Esophagogram revealed a defect of 5×5mm at the middle of the esophagus. Esophagoseopy showed a small elevated lesion with a part of reddish mucosa. Endescepic biopsy of its superficial erosion confirmed poorly differentiated adenocarcinoma. Barrett epithelium or ectopic gastric mucosa were not found. Endoscopic ultrasonogram suggested that this turnor was invaded into submucosal layer (sm3). Total resection of esophagus was performed. A size of lesion was 6×3mm. Histological examination of the resected specimen showed 0-I in the macroscopic feature, for the most part was poorly differentiated adenocarcinoma and some part was squamous cell carcinoma. But we could not diagnose it as adenosquamous cell carcinoma, assquamous cell carcinoma was limited to a small part. In addition, we presumed this tumor developed from the esophageal proper glands. Though the age of patients of adenocarcinoma of the esophagus is comparatively young, our case is the youngest in the literature as for as we know.

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We report a patient with pseudomembranous colitis complicated by toxic megacolon. A 19-year-old women visited our hospital because of severe diarrhea after administration of An abdominal plain CEX X-ray film showed toxic megacolon. Endoscopic examination revealed pseudomembranaus colitis. Her sympton and toxic megacolon disappered after vancomycin was administered. Based on a review of the literature, only 4 cases of pseudomembranous colitis with toxic megacolon have been reported in Japan. This is the 5th case of pseudomembranous colitis with toxic megacolon in Japan.

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We report a case of multiple metaplastic polyps of the colorectum in which one polyp had an area of invasive carcinoma and two polyps had intramucosal carcinoma in the metaplastic architecture. The patient, who was a 56-year-old man without a family history of colorectal polyps and a history of previous colorectal disease, underwent colonoscopy for constipation that revealed 22 polyps dispersed over the colorectum All ofthe polyps were resected colonoscopically, 18 with a snare device and 4 with hot biopsy forceps. The diameter of the metaplastic polyps ranged from 6 to 21mm, with a mean of 11.6mm. We termed the metaplastic polyps without a neoplastic component as M-type(metaplastic type), those with a neoplastic component as Gtype(coincidental type), and neoplastic polyps without a metaplastic component as n-type(neoplastic type). In this casewhich classified into MCn-type, pathological examinations revealed that of the 22 polyps, 15were M-type, 3were C-type, and 4 were n-type. The 3 of C-type comprised one invasive and two intramucosal carcinomas. Multiple metaplastic polyps of the colorectum is such a rare condition that only 30 case reports existed in the Japanese and English literature as of Sept. 1994' of these 24(including ours) were described in detiail. We classified these 24 cases of multiple metaplastic polypsof the colorectum into 4 groups; namely M-group if all of the polyps were M-type(9 cases), the MC-group if the polyps were M and C-type(3 cases), the Mn-group if the polyps wereMand n-type (7 cases), and the MCn-group if the polyps were M, C and n-type(5 cases). We compared these four groups with ranged to average age, sex, distribution of polyps, rate of the number of polyps over 100, and diameter of the biggest polyps. Our resultindicated that the MCn-and MC-groups mast frequently had carcinoma in the metaplasticpolyps, while the Mn-group most frequently had carcinoma in the neoplastic polyps. If neoplastic components are observed on biopsy of metaplastic polyps, we should consider coincidental carcinoma in the poiyps. We faund that as risk factors of carcinoma existingin metaplastic polyps, the polyps have a wide distribution over the coloreetum, the numberof polyps is usually ovor 100, and the diameters of the biggest polyps are more than 15 mm.

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A 69-year-old female had undergone partial gastrectomy. The resected specimen showed a protruding lesion(20mm×20mm in size)with an irregular reddish rnucosa associated with a superficially depressed lesion on the oral side. Histologically, moderately differentiated adenocarcinoma(tub 2)were observed in the gastric mucosa and in a nodular leson of the submucosa. Accumnulated xanthoma cells were found around the tub 2 tissue of the submucosa, and xanthogranulama around the nodule of the subrnucnsa. Intramural metastasis took place via veins or lymphatic vessels, forming a submucosal tumor like lesion associated with accumulated xanthoma cells and xanthogranuloma. This case was thought to be rare. The patterns of growth and invasion in this case were interesting.

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A 50-year-old woman was admitted to our hospital with a complaint of epigastralgia, who had an episode of a submucosal tumor in the gastric antrum detected by an endoscopyfive years ago. An endoscopy on admission revealed that the tumor had increased in size And the tumor was considered to have a cystic lesion on an ultrasonography and computed tomography. A wedge resection of the turnor was performed following a biopsy and a puncture which could show no particular findings on pathological study. On the macroscopic examination of the resected specimen, the tumor consisted of a yellow nodule 5mm in diameter and cystic components. The cyst was found to contain macinous fluid. The pathologic diagnosis was a gastric antral aberrant pancreas with a cyst formatiorn, which involved pancreatic acinar cells, ducts and a few numbers of islands of Langerhans. There are few reports that the aberrant pancreas associated with cystic lesion and that EUS studies were done in such cases. We report our case of the aberrant pancreas withacystic formation that was pointed out by EUS and reported cases in Japan.

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The patient was a 66-year-old female. Her immunological fecal occult blood was positive. Digital examination revealed an elastic, pedunculated mass to the 6 o'clack direction. Colonoscopy disclosed a hemispheric, broad-based, and protruded lesion 4cm from the anal verge. The lesion had a smooth surface with an erosion in its center. A subrnucosal tumor, especially a carcinoid or myogenic tumor or a malignant lymphorna, was suspected. Endascopic polypectamy was performed in order to establish the diagnosis. The excisional specimen measured 12×12×10mm, and was covered with normal mucosa. Histological examination of the specimen showed lymphoid follicular hyperplasia with germinal centers mainly in the submucosa. No atypical lymphocytes were found. Immunohistological staining did not show any monoclonality in the lymphocytes forming theprotrusion. A dignosis of benign lymphoid follicular polyp was then established. This isarare disease in Japan, and in this report, we discussed this case and some studies in theliterature.

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Case 1:a 23-year-old man who had suffered from Crohn's enterocolitis underwentsubtotal colectomy. In its recovery stage, he had a smart feeling in the esophagus. Case2:a 16-year-o1d girl with Crohn's colitis had been taking home enteral nutrition(HEN).She had a retrosternal stenotic feeling on swallowing. Case 3:a 23-year-old woman hadheart burn when she'was in the hospital for the treat:men.t of Crohn's e:nterocolitisr In thesethree cases, endoscopic examinations revealed aphthoid lesions in the esophagus. Esophageal Iesions of rahn's disease were found in 3 of 21 cases in our department. So wedo not think that they are rare cases. When patients with Crohn's disease complain ofupper GI syrnptoms, the esophagus shoud be carefully examined.

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We have experibnced a case of blind loop ulcer cansing intermittent massive bleeding.The patient was a 72-year-old female who underwent gastrectomy and cholangiojejunostorny 6 years ago. She had repeated episodes of bloody stool and been anemic nearly everyyear, but no radical treatment had been given because the site of hemorrhage vvas unknown, and the symptoms were alleviated by conservative treatments. After the fifthepisode of bloody stool, bleeding from the upper small intestine v as confirmed by hemorrhage scintigraphy and angiography. Since hemostasis was not achieved by conservativetreatments, emergency operation was carried out, and multiple ulcers were detected byintraoperative examination including endoseopy in a self-filling loop formed an theduodenal side of Roux-en-Y anastomosis. The previous 4 episodes of intermittent bleedingwere likely to have been from these blind loop ulcers. Close examination with the possibilityof blind loop ulcer is considered to be necessary, though this possibility may besmall, in patients who have a history of digestive tract anastomosis and are suspected tohave intestinal bleeding.

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In Case 1, a 27-year-old male, signs of ulcerative colitis were airserved by endoscopyfrom the rectum to the middle ascending calan. No abnormalities were Hated from theupper ascending colon to the cecum, but small ulcers and erosions were observed at theorifice of the appendix. In Case 2, a 57-year-old mLale, signs of ulcerative colitis wereobserved by endoscopy from the rectum to the sigmoid colon. No abnormalities were notedfrom the sigmaid colon to the cecum, but small ulcers and erosions were observed at theorifice of the appendix. Similar cases in Japan were reviewed, and the significance ofappendiceal lesion in ulcerative colitis was evaluated.

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A 54 year-old female with a history of rheumatoid arthritis for more than fire yearswas admitted due to progressing watery diarrhea and vomiting. Endoscopic examinationfor upper and lower gastrointestinal tract failed to show any specific findings foramylaidcsis, but revealed wide range of non-specific inflammatory changes such as redness, erosions and irregular shallow ulcers. Punch hiapsy specimens taken from both upperand lower gastrointestinal tract showed deposition of amyloid, which was confirmed byCongo-red stainings and immunostainings for amyioid A protein. Thus the patient wasdiagnosed as amyloidosis secondary to rheumatoid arthritis. She had been well for severalmonths by TPN, and died by heart fallure. Although amyloidosis is commonly accepted asasystemic disease, a few cases have been reported so far with some Iesions throughout thegastrointestinal tract. It is suggested that frequent endoscapic exarnination may be helpfulfor not only making accurate diagnosis but also understanding rapid changes in intestinallesions of patients with amyloidosis.

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A 47-year-old man received blood transfusion during surgical repair for femoralfracture in 1967. In 1993, he was found to be positive for HCV antibody. In August 1994, he was admitted to our hospital for the detailed investigation and treatment. Abdominal US and CT scanning revealed enlargement of the left lobe of the liver. The right lobe wasnot observed and the gallbladder was displaced and contiguous to the right abdominal wall.On abdominal angiography, the right portal branch and right hepatic artery were notobserved. On laparoscopy, the lateral segment of the left hepatic lobe was enlarged andextended to the middle of the normal right lobe site. The quadrate lobe was contiguous tothe right abdominal wall as was the gallbladder. The liver surface showed peliosis at area No. 200 according to the classification of Shimada. Biopsy of the liver revealed inactivechronic hepatitis. based on these findings, this patient was diagnosed as having a defectof the right lobe of the liver associated with hepatitis C. Although this defect is consideredto he rare, it will be reported more frequently in the future with the advances in noninvasive imaging diagnosis.

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Impaction of a gallstone in the cystic duct or in the neck of the gallbladder causes aseries of biliary tract diseases such as Mirizzl's syndrome, confluence stone, and biliobiliary fistula. These uncommon complications of gallbladder stones, therefore, should be dealtinclusively in diagnosis and the treatment. Recent advances in equipment of endoscopy and lithotriptor have enabled us non-surgical treatment of these pathologic conditions an effective and safe alternative to thetraditional surgical procedure. Then, we could treat Mirizzi's syndrome of 82 year-old male non-surgically. Thesingle stone 16×13 mm in size impacted in the dilated cystic duct was demonstrated bycontrast injection via the naso-biliary catheter and was fragmented. after 4 sessions ofextracorporeal shock wave lithotripsy using a Siemens Lithostar lithotriptor(16800 discharges in total). Prior EST allowed spontaneous clearence of the stone fragments smallerthan 5 mm in diameter and the patient had remained free of pain untill discharged. In conclusion, ESWL in combination with EST and N-B catheter is the first choice ofstrategy to manage complicated gallbladder stones because it is less invasive and saferthan any kind of other non-srgical procedures with LASER or electrohydrolithotriptor.

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A-75-year old man was admitted to our hospital with jaundice. ERC revealed astenotic area in the lower bile duct and the diagnosis by the biopsied specimen wasadenocarcinoma. The intra du.ctal ultrasonography revealed the longitudial invasion ashaving reached the middle section cf the bile duct, including the junction of the cystic ductand common bile duct. The depth of the tumor invasion was diagnosed as having xeachedthe adventitia fascia. The invasion into the pancreas was slight, at Pancl. The degree ofinvasion of cancer cellS confirmed by the histological examination of the resected specimenwas exactly consistent with the diagnosis made by the intra ductal ultrasonography. Thisfact suggests the accuracy of the diagnosis of by the intra ductal ultrasonography in thiscase.

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