One hundred fifty-six cases of elevated lesions in the duodenal bulb with histologicallygastric type epitheliurn were classified into two types, that is, heterotopic gastric mucosaltype accompanied with histologically perfect fundic glands tissue and gastric coveringepithelium(H type)and gastric epithelium metaplastic type accompanied only with gastriccovering epithelium without fundic glands tissue(M type), for comparative studies in orderto clarify differences between the two types. They could be classified into four groups byendoscopy, and this cndoscopic classification could be almost discrcminated between Htype and M type. Gastric mucosal atrophy was extremely love in H type cases. ln M type, no correlation was noted with gastric r:nucosal atrophy. As to Helicobacter pylori infection, presence of H. pylori in the stomach was comffirmed in 2 out of 22 cases (9.1%)of H type, suggesting the presence of some factor which would decrease vulnerability to H. pylori infection. H. pylori in the stomach was found in 120ut of 13 case(92.3%)of M typeIncidence of H. Pyliriinfection in the lesion of the duodenum was relatively low at 25%, or in 3 cases. lt was inferred that H type was noted with heteretopia, and M type wasmetaplasia.

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One hundred twenty-three cases of advanced colorectal cancers were classified into PG-Ca(intramucosal polypoid growth)and NPG-Ca(nonpolypoid growth). PG-Ca was 61 (49.6%)and NPG-Ca was 62 cases(50.4%). The mean age was 68.1±11.1years in PG-Ca and 60.3±11.6years in NPG-Ca. The average diameter of tumors was 5.7±2.7cm in PG-Ca and 4.3±2.1cm in NPG-Ca. Tumors less than 2 crn in size were 26.3%(5/19)in PG-Ca, and 73.7%(14/19)in NPG-Ca Tum.rs ranged fr.m 2.1 to5cm were 40.7%(22/54)in PG-Ca and 59.3%(32/54)in NPG-Ca. Tumors more than 5 cm were 68.0%(34/50) in PG-Ca and 32.0%(16/50)in NPG-Ca. Frequency of cancer with adenoma was 5.7%(7/123)of all cancers and 11%of PG-Ca. In small advanced cancers less than 2 cm in diameter, nave of case with adenoma was found. We conclude that NPG-Ca may be derived from nonpolypoid early cancer(flat type cancar) since there are different clinicopathological features between PG and NPG color-eCtal Cancers.

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We performed a retrospective study on the growth and extent of the extrahepatic bile duct carcinoma by serial endoscopic cholangiography in 30 patient swhich had been followed up by endoscopic biliary drainage without anti-cancer treatments. Cholangiographic findings of the tumor were classified into the following four types: papillary type in 7, nodular type in 13, nodular-infiltrative type in 8 and diffuse infiltrative type in 2. A mean time of the follow up period was 10.2 months, ranged from 1 to 90 months. In papillary or nodular type, the size of the tumor increased slowly, and infiltrative growth or extention to hilar portion were observed infrequently in approximately 20% of them. In contrast, extentian to hilar pardon was observed in most of the cases of nodular-infiltrative or diffuse infiltrative type. Prognosis was not necessarily related to types of the tumor or extention to hilar portion. Cholangiographic findings in onset, however, was considered to be a useful predictor of extention to hilar portion.

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Changes in gastric mucosal blood flow during the healing process of gastric artificialulcer caused by endoscopic mucosal resection were investigated by laser doppler flowmeter. In 191esions (19 cases), we examined mucasal bland flaw at the edge of artificialulcer and surrounding mucosa. In the course of ulcer healing, mucosal blood flow of ulcermargins increased significantly at the scarring stage compared with active stage(p<0.05).Put the surrounding mucosal blood flow was not significantly changed. In the early healedgroup, mucosal blood flow at the ulcer margins and surrounding mucosa is higher than inthose of the protracted group at the healing stage(p<0.05). This results is suggested thatthe speed of ulcer healing is depend on the supply of mucosal blood flow in the healingprocess of acute gastric ulcer.

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Despite the recent advance in the diagnostic equipments such as computerized tomo-graphy or endoscopic uitrasonography (EUS), non-invasive method of accurate diagnosisof myogenic tumor of stomach has not been well established. Thus, we studied clinical andhistopathological findings of eleven cases of leiomyosarcoma of stomach which wereresected in the recent seven years at our surgical department. As the results, the clinicalfindings such as patients'age or sex, and location of tumor or existence of ulcer formationon the tumor surface could not definitely determine whether the myogenic tumor ofstomach was malignant or not. On the other hand, EUS provided us important informatians on this problem. Especially, ultrasanagraphic inhamogeneaus pattern of the internalecho of the tumor and the sonolucent area of the tumor strongly suggested the possibility of leiomyosarcoma. Ten out of our eleverl leiomyosarcomas(90.9%) had the former EUSfindings and six (54.5%) had the latter. The sonalucent area of the leiomyosarcoma waslocated in the central area of the tumor and was irregular in the shape, the size beingmostly beyond 10 mm This ultrasonographic findings was considered to be pathologicallyidentical with the liquefaction necrosis of the tumor. Hewever, three cases of leiomyosarcoma less than 30 mm in diameter did not have a sonolucent area in the EUS image. But, the size of these tumors increased extremely rapidly during our follow up study by EUS.According to Collin's method, the doubling time of these three tumors were calcu.lated tobe 4.5, 11 and 14 months respectively. Thus, EUS amage at one stage can not alwaysdetermine whether a myogenic tumor is malignant or not, and the follow u.p study is necessary.

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To evaluate the detectability of EUS in waking diagnosis of gastric myogenic tumor, 12 cases of leiomyoma and 13 cases of leiomyosarcoma evaluated by EUS were studied.The results were as follows; 1) EUS findings were corresponded precisely to the histological findings (Table 3). 2) Tumor of which internal echoic pattern was type B or the one larger than 40mmof which echoic pattern was type C was assigned for malignancy. According to this sign, accuracy rate was 760%. 3) The change of internal echoic pattern or the rapid growth followed by EUS wassuggested to be the sign of malignancy. 4) EUS was very useful for differentiating gastric leiomyosarcoma from leiomyoma.

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Of 3, 540 patients of gastric cancer registrterd at our hospital from 1979 to 1993, 314patients (early cancer:261 patients, advanced cancer:53 patients) previously underwentupper gastrointestinal endoscopy were reviewed. No lesions or minimal changes and definite gastric lesions were found in 149 and 110patients, respectively, and the examination was inadequate in 55 patients. The rate ofadvanced cancer were 9.9% within 1 year, 9.7% in 2 years, 18.2% in 3 years, 27.3% in 4years and 31.8% in 5 years, respectively, in the time interval from the last endoscopicexamination Over 3 years in the group of definite lesions and 2 years in the group of nolesions or minimal changes the rate of advanced cancer increased markedly. ln order toreduce the rate of advanced gastric cancer the endoscopic examination should be recom-mended repeatedly within the intervals.

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We report a patient with achalasia complicated by esophageal ulcer. 48-year old malewas diagnosed as achalasia in 1982. He visited our hospital complaining of hematemesisin 9th March 1993. Emergency endoscopic examination revealed an esophageal ulcer(Dieulafoy-like) with active bleeding on the right-posterior site in the thoracic esophagus.The bleeding from esophageal ulcer was successfully controlled by endoscopic clippinghemostasis. Based on the review of literatures, only 2 cases of achalasia with esophagealulcer have been reported in Japan. This is the 3rd case of achalasia complicated byesophageal ulcer in Japan.

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A case of MALT lymphoma in a 50-year-old man was reported. Endoscopical examination done 6 years ago revealed a Iic like ulcerative lesion on the anterior wall of the lower body of the stomach. Biopsy specimen obtained from the lesion was interpreted as reactive lymphoreticular hyperplasia. He had been treated with anti-ulcer drugs for 7 years because of recurrent erosions, ulcers and cobblestone mucosal changes. During the period, the lesion persisted to be an ulceration endoscopically and RLH in biopsy diagnosis. When he complained of epigastric pain in Juiy 1992, endoscopic examination revealed a Borrmann 3 typecrater, 3 cm in diameter, on the anterior aspect of the angulus. Biopsy specirnen revealed MALT lymphoma (diffuse, B cell type). We thought in the retrospective study that this case could be a MALT lymphoma from the beginning.

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We reported a case of small lung cell carcinoma with gastric metastasis. A 62-year-old man was admitted to our hospital for further examination of a gastric suhmucasal tumor. The chest X ray film on admission showed a tumor-1ike shadow in the right lower lung field. CT-guided needle aspiration biopsy (CT-NAB) of the lung tumor proved small cell carcinoma. The upper gastrointestinal endoscopic examination showed a protruding lesion with central ulceration on the anterior wall of the lower body of the stomach. Gastroscopic biopsy of the submucosal turnor-1ike lesion demonstrated small cell car-cinama identical to the histological findings of CT-NAS specimens of the lung tumor. The patient was effectively treated with chemotherapy. The gastric metastasis from primary lung cancer rarely occurs and thecase in which the improvement of the gastric rnetastasis is confirrrled endoscopically, is very rare.

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The case Wasa 49-years-old male who visited our hospital complaining of decreased body weight and anorexia. Laboratory data on admission showed hypoalbuminemia and gastroendoscopy revealed hypertrophic mucasa in the gastricbody. Gastric juice analysis revealed hypoacidity and protein losing. This case was diagnosed as Menetrier's disease. Improvement was obtained by the treatment with famotidine and enteral tube elemental diet therapy. Serum pepsinogen (abbreviated as PG hereinafter) of the patient was determined before and after the treatment. Before the treatment, serum PG- and PG-II were both at abnormally high values, but the numbtrof cells containing PG granules decreased in the gastric mucosa. The difference between serum and gastric mucosa in PG-cotent was revealed. After the treatment, serum PG levels and distribution of PG granules in the gastric mucosa became normalized. This case was interesting from the point of view of elucidating the mechanism of transmigration of PG to the blood.

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A 74-year-old male was admitted to our hospital because of hematochezia.Endoscopic examination revealed three submucosal tumors showing Bull's eye appearance in the ascending colon.These tumors were diagnosed as metastatic cancerseconLdary to the lungcancer.In Japan, only twelve cases of metastatic colonic cancer secondary to the Iung were reported.Among them, only 4 cases revealed Bull's eye appearance.When by further examination, multiple Bulb's eye appearance is recognized, extra-abdominal primary lesions must be examined.

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A 22-year-old woman with ulcerative colitis has been followed up for two years since the establishment of the diagnosis; she has been asymptomatic for the past one year, under treatment with sulfasalazine 2g/day. She was admitted to our hospital with sudden onset of fever and diarrhea. In the laboratory findings, inflammatory parameters such as Creactive protein and ESR were elevated. Double contrast study of colon showed multiple barium flecks and edematous mucosa in the proximal portion of ascending colon and cecum. However the remaining colon and rectum showed coarse mucosal pattern alone. Colonoscopy showed multiple shallow ulcers in cecum and proximal ascending colon and the findings of quiescent colitis from rectum to transverse colon. The cultures of stool were positive for Salmonella isutanbul. Thus, she was diagnosed as salmonella colitis associated with inactive ulcerative colitis. Her symptoms and inflammatory signs disappeared after antibiotics were administered. Salmonella infection associated with ulcerative colitis has been rarely reported in Japan. This ease was the 7th one during the fast 23 years.

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A 82-year-old female was admitted to our hospital IOecause of severe anemia.Laboratory studies showed severe anemia and positive occult blood in the feces. Endo-scopic examination revealed longitudinal red stripes of dilated vessels in the gastric antrumand diffuse erythematous spots of dilated vessels in the pyloric lesion. Biopsy specimentaken from the antral mucosa demonstrated dilated vessels in the proper gastric mucosallayer, leading to a diagnosis.of gastric antral vascular ectasia (GAVE). She also hadprimary biliary cirrhosis. Since the gastrointestinal bleeding continued and anemiaprogressed, she was endoscopically treated with heateT probe, Such treatmet resulted inmarked improvement of dilated vessels and is useful for stop bleeding.

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Endoscopic retrograde biliary drainage(ERBD)has been widely adopted as an excellent therapeutic modality for biliary drainage in patients with malignant obstruction of thebiliary tract. A major disadvantage of this procedure is an obstruction of the drainagetube, which requires the replacement of the drainage tube every 3-4 months. To preventthe obstruction of the drainage tube an endoprosthesis with a larger diameter (14Fr.)has recently been on the market, but the insertion of this tube requires a large-diameter duodenal fiberscope (TJF-M20, Olympus)and is technically very difficult. We describe here a new method for the insertion of the 14Fr. ERBD tube. In this method, endoscopic transnasal biliary drainage (ENBD) with a 7.2Fr. ENBD tube was performed after endoscapic sphincterotomy. Several days later, a 14Fr. ERBD endeprnsthesis was inserted utilizing the previously inserted 7.2Fr. ENBD tube as a guiding catheter. This methodcould reduce the technical difficulty of the 14Fr. tube insertion and may prolong the period of the effective biliary drainage.

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In order to make a definitive diagnosis of polypoid lesions of the gallbladder and selectaproper operative procedure, 1aparoscopic cholecystoscopy and biopsy were perforrned inseven patients. Laparoscope and three trocars were placed as in ordinary laparoscopiccholecystectomy. Under laparoscopy, another 5 mm trocar with a balloon was transab-dominally inserted into the fundus of the gallbladder, which was held by three graspers.Then the balloon was inflated to fix the trocar, and the gallbladder was filled up withsaline. Either a 5 mm rigid scope or a fiberscope was inserted into the gallbladder throughthe trocar. Then the polypoid lesion was observed and biopsied for frozen section. Thediagnoses were a cancer in one patient, an adenoma in three patients and cholesterol polypsin three patients. A proper operative procedure (open cholecystectomy with lympha-denectomy, 1aparoscopic cholecystectomy or polypectomy) was selected in each patient.The final pathologic diagnosis was the same as the cholecystoscopic diagnosis in allpatients.

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