The relationships between Helicobacter pylori(H. P.) inection and duodenal mucosal hemodynamics were analysed by the reflectance spectrometry in duodenal linear ulcers in order to find the influence of the therapies, such as proton pump inhibitors, H₂-blockers and an eradication of H. P., on the hemodynamics. The mucosal flood flow increased at the anterior wall to the ridge in the duodenal bulb, where ulcers are tended to present, regardless of duodenal ulcer stages. There was no hemodynamical difference between the red scar stage (S₁) and the white scar stage (S₂) with either conventional acid suppressive therapies or no therapy. Intramucosal oxygen saturation (ISO₂) at the end of an eradicational therapy (2W)-omeprazole 40mg bid plus arnoxicillin 1500rng tid for 14 days-tended to be higher than that of the beginning of the therapy (0W) in the cured H. P. cases. ISO₂ at 4 weeks after the end of therapy (6W) tended to be lower than that of 2w. Intrarnucosal hernoglobin volume (IHB) at 2w was statistically reduced than that of 0w (P<0.05). Eradication of H. P. brought the improvement of duodenal mucosal hemodynamics resulting the higher qualityof ulcer healing in duodenal linear ulcers. In H. P. eradicated cases, ulcers were not recurrent during 24 weeks-follow-up period. H. P. eradication is considered to lie very useful and to contribute for preventing ulcer recurrence.

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To evaluate the ability of intraluminal ultrasonography (ILUS) with a rnicroscanner in diagnosing the depth of invasion of gastric cancer, 115 lesions of gastric cancer (early; 100, advanced; 15) were studied. The microscanner (MP-PN 20-06, Aloka Co. LTd.) applied in this study was a mechanical radial scanner with a frequency of 20/15 MHz and a diameter of six Fr. Due to its small size, the scanning of gastric lesion through the channel of a gastroscope was possible. The images obtained by the microscanner were compared with the histological findings of the resected materials in each case. In 100 lesiens of early gastric cancer, accuracy rate of the depth of invasion estimated by microscanner was 91%in m-sml cancer and 67% in sm2 cancer. We classified early gastric cancerous lesions into three groups by macroscopic findings and patterns of fibrosis. In elevated type, accuracy rate was 94% in m-sml cancer and 100% in sm2 cancer. In depressed type without fibrosis, accuracy rate was 93/ in m-sml cancer, and 83 in sm2 cancer. In depressed type with fibrosis, accuracy rate was 86% in m-sml cancerand 0% in sm2 cancer. In 15 lesions of advanced gastric cancer, the depth of invasion was diagnased accurately in 25% of mp cancer, 50% of ss cancer and 33% of se cancer. From these results we conclude that ILUS with a microscanner is excellent in evaluating minute cancerous lesions without fibroses. And PLUS is useful for the determination of indication of endoscopic mucosal resection in gastric cancer. But, this technique is unsuitable for the diagnosis of the depth of advanced gastric cancer.

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We performed percutaneous biliary ultrasonography with the thin ultrasonic probe through a percutaneous transhepatic biliary drainage catheter. The normal papilla of Vater consists of five ultrasonographic layers. From the luminal side the high echo (layer 1a) of the first layer corresponds to the mucosa of the common duct. The low echoic area (layer 1b)of the first layer corresponds to the sphincter of Oddi. The second hyperechoic layer corresponds to the submucosa of the duodenum. The third hypoechoic layer and the fourth hyperechoic layer correspond to the mucosa of the duodenum. When the probe was contact with the lumen, the first and second layer was displayed as only a hypaechaic layer. In 10 patients with cancer of the papilla of Vater, accuracy rate of PBUS diagnosis on cancer extension was studied. Accuracy rate on the diagnosis of duodenal invasion was 100%, and that of pancreatic invasion was 90%. PBUS with the thin ultrasonic probe provides an effective imaging for the evaluation of the extension of cancer of the papilla of Vater.

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We have previously reported on the usefulness of the endoscopic rnucosal resection in the stomach using a ligating device. Based on this experience, we tried to establish the safe and reliable technique of the mucosal resection, endoscopic mucosal Iigation (EML). We confirmed the usefulness of this technique and applied it clinically. 1 week after EML with submucosal injectian of physiological saline solusion, about 13mm in diameter of the mucosa fell out safely and correctly, while the surface of the proper muscular layer wask eptintact. 1 week after EML without submucosal injection, this procedure induced the dissection of submucasa and a part of proper muscular layer about 20mm in diameter. We performed this EML procedure in four patients. Follow-up endoscopic examination confirmed that gastric lesions were completely resected and not recured. It is concluded that EML procedure is easy and valuable treatment modality.

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It is well known that some social background in Japan including dietary custom has been changing in recent years. Some changes may have influenced the Japanese peptic ulcers. The purpose of this report is to find out some of the changes of gastric ulcer and duodenal ulcer or both in endoscopic findings and clinical features over recent years compared with ten to fifteen years ago. Of 1, 995 patients who underwent the first endoscopic examination by a special endoscopist at Tohoku Rosai General Hospital in five years starting from 1979, 424 patents were classified into the former group (diagnosed as gastric ulcer, duoderlal ulcer, or both). Of 1, 776 patients in five years starting from 1988, 343 patients were classified into the latter group. Comparative study was made in terms of sex, age, complications, endoscopic findings of peptic ulcers. As a result, the following were recognized; 1) decreased incidence of gastric ulcer and increased incidence of duodenal ulcer (especially zn younger generation and female), 2) increase in ulcers at body of the stomach (P<0.05), 3) decrease in large, deep ulcers and inlcrease in small, shallow ulcers (P<0.05). They may be the causess of ulcer in accordance with changes in social background.

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We experienced 8 eases of esophageal granular cell tumor in the past 3 years; 7 were endoscopically resected and one has been frequently observed by endoscopy. We studied endoscopic appearance and EUS findings of these tumors. The results were as follows; 1) Endoscopically, yellowish white submuCasal tumors similar to molar tooth were characteristic in esophageal granular cell tumor. 2) No cases were diagnosed as granular cell tumor by endoscopic biopsy. 3) Esophageal granular cell tumors were imaged by EUS as homogenous hypoechoic mass with clear border and smooth margin. 4) EUS was useful to diagnose the depth and invasion of granular cell tumor. 5) Endoscopic resection should be taken into consideration as the first choice if the tumor is limited to the submucosal layer.

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A 72-year-old male who underwent subtotal esophagectomy and esophagogastrostomy for esophageal carcinoma complained of severe dysphagia. Endoscopic examination revealed an anastomotic stricture with no recurrence of carcinoma, and balloon dilatation was immediately performed and repeated 4 times in 7 months because of its temporary effect. Following the 4th balloon dilatation, 4mg dexamethazone was endoscopically injected into the scar tissue, and no recurrent anastomotic stricture has been found thereafter. In conclusion, locally injected dexamethazone would be effective for prevention of recurrent anastomotic stricture following balloon dilatation.

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During admission to our hospital for Herpes Zoster, 72-year-old male suffered from recurrent gastric bleeding due to gastric ulcer with humped artery. As two times endoscopic hemostasis was not effective, arteriography for the parietal branch of left gastric artery was carried out. Arteriography showed an aneurysm at the bleeding site. Endoscopic hemostasis was considered to be ineffective for the bleeding from the aneurysm, because of thick artery in diameter. Transcatheter arterial embolization (TAE) utilizing N-buty1-2-cyano-acrylate achieved complete hemostasis. Endoscopic hemostasis seems to have limitation in gastric aneurysm. So it is important to refrain from repeating endoscopic hemostasis and to choose TAE as a hemostatic procedure in this case.

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We herein report a case of 69-year-old man who was endoscopically diagnosed as having a gastric submucosal tumor, and had been followed up for the subsequent 5-years. He was admitted with complaints of general fatigue and black stools. Previous endoscopical examination showed non-remarkable change in the tumor size;lcm in February 1989, 1.5cm in November 1990, 2.5cm in August 1992 and 1.5cm in September 1993. However, the tumor has rapidly become larger, 4cm in diameter, after an interval of 8 months. The tumor was located in the cardia, and was accompanied with ulceration. bleeding was slightly seen in the cavity. Endoscopic ultrasonography demonstrated that the tumor showed a heterogeneous echo-pattern with a hypoechoic lesion. Though the tumor was suspected to be a leiomyosarcoma, the biopsied specimens showed no information histologically. The operative findings showed that the tumor was remarkably exophytic in growth. No metastases or invasion to Other organs was detected, and proximal gastrectomy was performed. Macroscopically, the tumor was 65×55×45mm in size, and showed a yellowish cut surface with partly necrotic lesion. Histopathological diagnosis was leiomyosarcoma of the stomach. As reported previously, smooth muscle tumors of the stomach, especially those larger than 2cm, sometimes show a rapidly growth in a short period. We, therefore, propose that submucosal tumors larger than 2cm in size should be examined exactly by endoscopic ultrasonography, and be either followed up at short intervals or treated by resection of the tumor. Tumors less than 2cm in size, however, mad be followed up at longer intervals.

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A 71-year-old female was admitted to our hospital for the evaluation of duodenal tumor, which was incidentally detected by endoscopic examination. The hypotonic duodenography demonstrated flat elevating lesion (2×2cm) in the duodenal second portion. Endoscopic examination showed the mufti-nodular protruding lesion, which was covered with thick whitish mucasa. Biopsy specimens taken from this lesion revealed marked infiltration of atypical lymphocytes, suspected non-Hodgkin's lymphoma (NHL). Endoscopic ultrasonography showed that the tumor located within the submucosa. Local resection of the duodenum was performed. Histologicaily the tumor was diagnosed as NHL (follicular, medium-sized cell type) spread involving the su.bmucosa, and immunohistological study revealed tumor cells were B-cell origin. Furthermore, gene examination showed the rearrangement of Ig(JH). Adjuvant chemotherapy is now on going. This case, early nan-Hodgkin's lymphoma of the duodenum, was exceedingly rare.

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A 80-year-old wornan was admitted to our hospital because of further examination of pneumonia and dilated common bide duct. Endoscopic findings showed semipedunculated and reddish tumor with granular and lobular appearance in the second portion of the duodenum. The biopsy specimen showed tubuio-villous adenoma, but a pancreaticoduodenectomy was performed. The surgical specimen showed type Isp tumor with granular and lobular appearance measuring 40×35×20mm in diameter, at the anal part of the papilla of Voter. Histological examination of the resected specimen showed vvell differentiated adenocarcinorna with invasion limited to the mucosal layer With tubulo-villous adenoma. No lyrnph node metastasis was seen. The authors reviewed 249 cases of early duodenal cancer in Japanese literature (1968 to 1994).

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The authors presented a case of 49-year-old female with Brunner's gland hyperplasia of duodenum diagnosed by EMR. Upper gastrointestinal endoscopy showed a flat elevated lesion with central umbilication at the anterior wall of the duodenal bulb, which was diagnosed as tubular adenoma with mild to moderate atypia by ordinary biopsy. Adenomas of duodenum, similar to those of colon, involve the problem of adenamamcarcinoma sequence, and yet it is difficult for the mere endoscopical findings to make a differential diagnosis from benign tumor to malignant one. Therefore, to make a deffinite diagnosis, EMR was performed. Histolagieal findings of the resected specimen revealed Brunner's gland hyperplasia. There are some cases that the ordinary biopsy cannot lead the correct diagnosis, in these cases, EMR was thought to be useful.

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A case of mesenteric panniculitis of the sigmoid colon is described. A 61-year-old maie was admitted to our hospital complaining of left lower quadrant pain and palpable mass. Barium enema examination revealed a narrowing of the sigmoid colon and sawtooth-like appearance on the mesenteric side. Colonofiberscopy showed red and edematous mucosa, but the biopsy specimen revealed no remarkable findings. Abdominal CT scan revealed the enlarged fat-density mass surrounded by the colon wall. The diagnosis of mesenteric panniculitis was based upon these findings. We treated the patient successfully with broad-spectrum antibiotics instead of surgical procedures. A fallow-up barium enema study after 1 month showed marked improvement of the lesion. The patient is doing well without recurrence.

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Arare case of Heyde's syndrome is reported. The patient was a 71-year-old female. She was diagnosed as having aortic stenosis and insufficiency at another hospital and was admitted due to massive bloody stools. Endoscopy fo the upper and lower digestive tract and angiography showed no alanormalities, and the patient was referred to our hospital. She had another episode of massive bloody stools after 3 months. Vascular octasia was detected in the ascending colon by colonoscopy, and endoscopic treatments were performed. Recurrent gastrointestinal bleeding complicated aortic stenosis and vascular ectasia is termed Heyde's syndrome. The condition is common in Europe and America but is rare in Japan.

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A 37-year-old male was hospitalized due to right lower abdominal pain. He had no history of gastrointestinal polyposis, von Recklinghausen's disease, or multiple endocrine neoplasia type 2b (MEN type2b). Barium enema and colonoscopy were performed and revealed a reddish, slightly elevated lesion in the ascending colon. It was treated by endoscopic mucosal resection. Microscopiccally, there was proliferation of ganglion cells and interlacing bundles of nerve fiber within the lamina propria. Immunohistchemical stains revealed S-1aa protein and neuron-specific enolase to be positive for the lesion. The peculiar findings of this lesion are discussed and literature is reviewed.

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A 78-year-old male was admitted to our hospital for bulging of bilateral inguinal regions. Preoperative diagnosis vvas bilateral direct inguinal hernia. Laparoscopic exaxnination revealed left supravesical hernia and right direct inguinal hernia. Laparoscopic repair of transabdominal approach using Prolinmesh was performed correctly far each hernia. Supravesical hernia is so rare, only g eases including our case has been reported in Japan. By laparoscopic procedure we could identify anatomical location of supervesical fossa and perfarm accurate surgery.

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We reported two cases of endoscopically confirmed paraileocecal abcess in which pus was found to drain to the colonic lumen. The first patient was a 78 year old man who presented with abdominal mass of the right lower quadrant. The imaging studies showed abdominal mass in the ileocecal region. The endoscpic examination revealed tumor-like protrusion of the cecal mucosa and pus was leaked from the biopsy site. He was diagnosed as paracecal abcess due to appendicitis by operative and pathological findings. The second patient was a 42 year old man who was admitted for pain in the right lower quadrant of the abdomen. The imaging procedures showed mass close to the ascending colon. The endoscopic examination revealed a protruded lesion just above the ileocecal valve and pus was draining spontaneously from the small opening of the tip of the m lesion. The diagnosis of paracolic abcess due to perforation of the diverticulum was confirmed by operative and pathological findings. We are sure that the endoscopic findings described as above are exceptionally rare and significant.

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Adaptating endoscopic variceal ligation using numerous O-rings for esophageal varices (eradicative EVL:eEVL) was performed on 10 patients for the eradication of esophageal varices. The efficasy of eEVL was evaluated by the ultrasonic miniture probe (UMP) as well as endoscopic findings at the end of therapy. The procedure of eEVL is as follows. During the first and second therapy the endoscopist ligated the varices in two places daiogonally just below the esophagogastric mucosal juncton (EG-j) and then ligated other higher varices at another diagonal at the nearest level possible. These procedures were repeated until 8-10cm above EG-j. After the second'therapy endoscopist ligated only a part of the varices and/or non-variceal area between ulcers formed by Previous EVLs. eEVL was performed at intervals of one to two weeks. The mean frequency of treatmentwas 4.2±0.8. The mean total number of O-rings used for eEVL was 40.4±11.6. Complete eradication of varices was obtained in all cases without any serious complications. After eEVL there were no varices in the mucosal and s'ubmucosal layers in the lower esophagus. Thickened those 2 layers (3mm or more) compared with the layers before eEVL was observed in UMP imagings. Therefore eEVL is proven itself to be more effective and free of serious complications in comparison with standard EVL treatment.

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