A total of 245 patients with bleeding gastric ulcer were studied with special reference to the risk of rebleeding. The clinical backgrounds and endoscopic findings on admission were evaluated whether they could predict rebleeding. Arnong clinical backgrounds, age, sex, or initial manifestation of GI bleeding (hematemesis or melena) showed no predictive value of rebleeding, while presence of concomitant diseases and shock on admission were associated with high risk of rebleeding. Analysis of endoscopic findings revealed that a white protuberance, pigmented spot, thin clot, and clean ulcer base were related to the low risk of rebleeding. In contrast, patiehts with arterial bleeding at endoscopy and a red mound were at high risk for rebleeding. Our present study suggested that the most important predicting factors of rebleeding in bleeding gastric ulcers are arterial bleeding and a short interval from the latest hemorrhage.

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We examined the relationship between the degree of submucosal infiltration, lymphnode metastasis and vascular invasion in resected sm carcinoma specimens of 525 patients. The degree of vertical submucosal infiltration was classified into four stages, namely, smla, smlb, sm2 and sm3. The degree of horizontal infiltration was classified into five stages, namely, H0, H1, H2, H3 and H4. Specimens of each stages were examined for the presence of ulcerative lesions in foci according to the degree of sm infiltration, for lymphnode metastasis and vascular invasion according to the tissue form. Lymphnode metastasis was not observed in cases of smla of the protruding type of 20mm or smaller 0/2;0%. Lymphnode metastasis was not observed in any cases of highly differentiated adenocarcinoma, and smla of excavated type without ulceration 0/16;0%. Vascular invasion was noted in 2 of 16 cases 12.5% of highly differentiated adenocarcinoma of smla, and excavated type without ulceration. These findings suggested that, for deciding endoscopic therapy in sm carcinoma, the cases should be those of highly-diffentiated adenocarcinoma of smla of 20mm or smaller without ulceration.

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The aim of this study was to evaluate the clinical significance of duodenal ulcer scarsjust beyond the pyloric ring found by screening examinations using a transparent-tip-hood-fitted magnifying electronic endoscope(O1ympus, GIF-200Z). Atransparent tip-hood wasvery useful for magnifying observation of duodenal mucosa just beyond the pyloric ring.Duodenal ulcer scars were found in 52 of 160 patients undergoing endoscopic examlnatlon.Among 56 ulcer scars, 51.8%were on the anteroinferior wall of the duodenal bulb, 25.0% on the posterior wall, and 23.2% on the.superior wall. Twenty-seven of the 56 ulcer scarscould be observed without a transparent tip-hood and 85.2%were on the anteroinferiorwall. Background duodenal fine mucosal pattern was classified into three patterns, i. e., isolated pattern, connected pattern, and atrophic pattern. Among 52 patients with duodenal ulcer scar just beyond the py1oric ring, 42.3%had isolated pattern, 55.8% connected pattern, and 1.9%atrophic pattern. There was no influence of the existence of duodenal ulcer scars just beyond the pyloric ring upon the insertion into the duodenal bulb. Achange in detective frequency of duodenal ulcer scars was thought to have a greatinfluence on not only epidemio1ogical value but also the study on duodenal ulcers for thefuture and clinical treatments for active duodenal ulcers.

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Emergency colonoscopy was performed in 35 patients with bloody stoo1(hematocheziaor melena)except for hemorrhoidal bleeding. It was fou:nd that ischermic colitis(IC)wasthe most frequent in lower gastrointestinal bleeding(14 of 35 patients;40%)which neededernergency colonoscopy. The comparative study of IC group(n=14)with non-IC group(n=21)showed obvious difference between the two groups as fo110ws;1)IC group often had'preceding symptoms su.ch as abdominal pain(85.7%)or diarrhea(57.1%)before suddenonset of bloody stool, but non-IC group developed without any preceding symptorn(66.7%). 2)Leucocytosis was characteristigally recognized in IC-group(57.1%).3)In IC-group, themean age was 61.5years ranging between 35 and 77 years and rnost of them were female(85.7%).In contrast, the mean age was 53.Oyears ranging between 25 and 86 years andrnale were slightly more susceptible(57.1%)in non-IC group.4)In IC-group, the transverse(30%), descending(60%)and sigmoid colon(10%), but not the ascending colon orrectum were mainly involved. On the other hand, any site of the colon was involved in non-IC group. The further study to clarify clinical fgatures of IC reveal6d slight different results from those of other studies. The differences were as follows;1)Constipation was seen in 6 of 14 patients(42.9%), but on the other hand, arteriosclerosis-related diseases were seen inonly l patient(7.14%).2)The frequency of transient type IC in our study was higher thanin other studies.3)There were 3 cases of IC in young adults(21.4%).4)It was possiblethat the habit of heavy drinking as well as th6 pretreatment with oral polyethylene glycolelectrolyte solution for colonoscopy could induce IC.5)There was 3 case of recurrent IC.6)There was an atypical case, suggesting that clinical features of IC were more heterogeneous than expected. This study suggested that careful observation and positive colonoscopic exarninationfor the patients with sudden onset of bloody stool was necessary in order to catch subclinical IC cases.

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Straightening of the scope is desirable in endoscopic retrograde cholangiopancreatography (ERCP). But the success rate of scope-straightening was 75.4% in our previousseries. Then, we reported the initial use of a stretching balloon to increase the success rateof scope-streching. The balloon was applied to the tip of the duodenoscope. When thescope reached the second portion of the duodenum, this balloon was inflated with approxi-mately 30ml of air. The cannulation into the papilla df Vater was carried out after thescope was withdrawn gradually. We have successfully used this balloon for scope-stretching in all of 35 patients. This method has sorne advantages as follows : (1) Easy straightening of the duodenLoscope. (2) Preventing of the endoscope slipping into the stomach during ERCP examinatior1. (3) Being able to get clear photographs without reflux of contrast medium into thestomach. (4) Feusible hemostasis after polypectomy or endoscopic sphincteropapillotorny bycompression with the balloon.

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The shallow and fine parallel wrinkles (parallel wrinkles) were observed in 55 cases (29.6%) by ICG scattering method at laparoscopic examination of 186 cases of various liver diseases. In contrast to high detection ratio of parallel wrinkles in chronic inactive hepatitis (55.2%), acute hepatitis· (42.9%), nonspecific reactive hepatitis (40.0%) and others (75.0%), the ratio in liver cirrhosis (0%), chronic alcoholic liver injury (13.3%), chronic active hepatitis (28.6%) and fatty liver (28.6%) was sustained to be low. Histologically, fibrosis and activity in positive cases of parallel wrinkles was signifi·cantly weaker than in negative cases. Furthermore, the titer of serum type IV collagen 7S in positive cases was significantly low. There was no significant subcapsule change corresponding to parallel wrinkles at punch biopsy of parallel wrinkles. In one case parallel wrinkles disappeared during laparoscopic examination. In three cases these findings appeared with subsiding of hepatitis. These results suggest that parallel wrinkles are not permanent findings. Therefore, it is considered that parallel wrinkles may reflect hepatic flexibility and demorlstration of these findings is useful for accurate macroscopic diagnosis at laparo-scapic examination.

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A 43-year-old woma:n was admitted to our hospital cornplaining of tarry stool. She had received treatment for duodenal ulcer for S months. Gastroduodenoscopy shoVVed a tumor with a deep ulcer on the 2nd portion of the duodenum. After abdominal angiography, US, CT and EUS, the lesion was diagnosed as leiomyosarcoma and pan-creaticoduodenectomy was performed. The tumor was 46x43x40mm in size, and the central part of tumor was a necrotic cavity which was Iinked with the duodenal mucosa by the fisteL Histologically most of this turnor was composed of cells with vacuolated round epithelioid cells with eosinophilic cytoplasm. The final diagnosis was made as leiomyohlas-toma from these findings.

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Acase of early duodenal cancer treated by endoscopic mucosal resection (EMR) isreported. In a 72-year-old man, an elevated lesion (6mm in diameter) in the 2nd portionof the duodenum was detected during a routine endascopic examination that was perform-ed to monitor recurrence of a gastric ulcer. Because of irregular granules on the surface, this small lesion appeared to be a malignant tumor. This endoscopic diagnosis wasconfirmed by histological examination of biopsy specimens, which revealed a moderatelydifferentiated adenocarcinoma. Invasion of the tumor was examined by an ultrasonicprobe inserted through a channel of the endoscope. Clear sign for submu.cosal invasion ofthe lesion, which was demonstrated as a hypoechoic mass, was not detected. Because ofthe patient's age, bath he and his family didn't want surgery. Thus, we decided to treat thislesion by EMR. The procedure was performed successfully without complication. Stereo-microscopic observation of the resected specimen demonstrated irregular mucosal pits onthe lesion (8×6mm), suggesting malignancy. Since mu.cosal pits around the lesion wereintact, the tumor was completely resected. Detailed histological examination of theresected specimen showed that this moderately differentiated adenocarcinoma was locatedmainly in the mucosal layer, but in part, in the submucosa. Despite the submucosalinvasion, no invasion into veins or lymphatics was observed, indicating a low probabilityof metastasis outside of the duodenum. The indications far treatment of duodenal cancer by EMR are not yet-established.However, this safe technique promises to be a highly useful fool for detailed histologicalevaluation or treatment of early duodenal cancer.

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We reported two cases of perforated duodenal ulcer treated with non-oerative methodin childhood. Case 1 was a 15-year-old man who was admitted to ou.r emergency centeron June 18, 1994 with chief complaint of the sudden upper abdominal pain. The tendernessand muscle guarding were found in the abdomen on adrnission. Plain abdorninal X-rayrevealed free air in the bilateral subphrenic cavity. Ultrasonography showed slight fluidcollection in the Morison pouch. Emergency esophagogastroduodenoscopy(EGD)revealedan open ulcer with perforation 3mm in diameter in the duodenal bulb. The diagnosis of aperforated duodenal ulcer(PDU)was made and the conservative therapy which has beenmainly selected for the adult PDU in our department since 1988, was indicated. The clinicalsymptoms were improved 5 days later. EGD on the 5th hospital day showed the perforationto have closed on the ulcer base. His subsequent clinical course was uneventful anddischarged on the gth hospital day. Case 2 who was 13-year-01d man was similar to caselin the clinical Course and discharged on the 14th hospital day. We suggested that PDU in childhood was a gofld candidate for the conservativetherapy, because the healing of the duodenal ulcer in childhood was generally thought to befaster than in adult, if peritonitis following PDU could be carefully observed with non-operative method.

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A 73-year-old male was admitted to our hospital because of intermittent bloody stoolfor 3 months'duration. Endoscopic and X-ray examinatio:ns showed easily bled, protrudedlesion in the sigmoid.colon and flat elevated lesion in the rectum. A diagnosis of mucosalprolapse syndrome was made from the history of constipation, straining and the histological findings of fibromusculosis. Steroid therapy for 4 weeks was not effective, soendoscopic mucosal resection was performed far the rectal lesion and surgical procedurefor the lesion of sigmoid colon, respectively.

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A 41-year-old female with a history of 50perations for papillary carcinoma of thethyroid consulted our department due to abdominal pain in July 1992. Exploration of theTower digestive tract revealed dense growth of adenomatous polyps diffusely spread overthe entire length of the colon, and type 2 cancer causing circumferential luminal stenosisin the transverse colon. Chest X-ray and lung CT studies showed 3 nodules suggestive ofmetastasis. A diagnosis of familial adenomatous polyposis associated with carcinoma ofthe colon and thyroid was made. Total colectomy, ilearectal anastomosis, and partial lungresection were performed. Familial adenomatous polyposis is known to develop coloncancer in 100%of the cases when it remains untreated. A case of familial adenomatouspolyposis associated with papillary carcinoma of the thyroid, which is rare, is describodwith a review of the literature.

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A 49-years-old man visited our hospital with a complaint of lower abdominal pain.Barium enema study and total colonoscopy revealed multiple carcinomas of the colon andrectum. A lesion (type Isp, carcinoma in adenoma) in the rectum and two polyps (tublaradenoma) were performed endoscapic polypectomy, and a subtotal calectomy were carriedout. Histological examination of the resected specimens of the colon revealed a carcinomain adenoma type Is (well differentiated adenocarcinoma;well), a subserosal-infiltrated (; ss) type 2 (moderately differentiated adenocarcinoma;mod), and four polyps (tublaradenoma) in the sigmoid colon, and a mucosal-infiltrated type IIa+IIc (well) in thedescending colon, and a submuLcosal-infiltrated (; sm) type Is (well), and a propermuscular-infiltrated type 5 (well) in the splenic flexure, and a mucosal localized type Is (signet-ring cell carcinoma and well) in the hepatic flexure, and a sm type Is (well), a ss type 1 (mod), and a serosal-infiltrated type 2 (mod) in the ascending colon. This case was very few case that synchronous multiple carcinomas of the cooninculuding and early signet-ring cell carcinoma.

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The first case was a 43-year-old male and underwent an endoscopic polypectorny forarectal pedunculated tumor 2.5cm in diameter. The second case was a 58-year-old maleand underwent a transanal resection for a semi-pedunculated tumor as large as 1.8cm inthe rectum. Macroscopically both tumors had a central depression and microscopicallythose were diagnosed as carcinoid tumors.'Since in the resected specimens the first casehad lymphatic infiltration of carcinoid cells and the second case had muscular invasion bytumor cells, additional radical operations were performed. Based an the analysis of ourexperience with II cases of rectal cartinoid tumors including these two cases, diagnosticrnethods and therapeutic plans for the cases of malignant rectal cartinoid tumors werereviewed in the literatures and reported.

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A 27-year-old man was admitted to hospital in November, 1989 for sudden onset ofabdominal pain, general fatigue and a full sensation of the abdomen. Laboratory datashowed GOT27mU/dl, GPT43mU/dl, ALP319mU/dl and T. Bill.5mg/dl. Ultrasonicimages and CT scan showed hepatic vein obliteration and ascites. Hepatic venographyconfirmed the diagnosis of hepatic vein thrombosis(Budd-Chiari syndrome). Peritoneo-scope revealed that:the caudate lobe was markedly enlarged and innumerable lymphvesicles were seen an the capsule. Histology of the liver showed liver cirrhosis with hepaticcongestion.

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Endoscopic sphincterotorny (EST) in patients with previous Billroth II gastrectomy isusually difficult to perform for incomplete observation of the cutting point and controlcutting direction, because of the reverse approach to the papilla. To solve these problems, we tried to place in advance the endoscopic biliary stenting (EBS) tube or the bilianasaldrainage (BND) catheter into the cornrnon bile duct a saguide for cutting the papilla withaneedle type papillotome. This allowed us easy to observe cutting, point and direction, andEST was done safely and steadily. Moreover, even in the cases whereby the insertion ofendoscope to the papilla was difficult, EST could be performed at first insertion when EBStube was used. This technique will expand the indication of E5T to patients with Billroth II gastrectomy who are regarded as technical difficult cases and kept at a distance from EST.

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The advent of H₂ blockers resulted in the virtual demise of elective duodenal ulcer surgery. There is no doubt that most duodenal ulcers can now be healed by medication. Only a small percentage of duodenal ulcers prove resistant to H₂-receptor blockade arid Na pump inhibitor. But, more patients are becoming weary of long-term medication, especially as the majority of them are young to middle-aged active individuals. Whether the gastrin release by insulin-induced hypoglycemia is influenced by not only vagal stimulation, but also endogenous adrenalin from the adrenal medulla is of extreme interest. As far acid secretion in insulin-induced hypoglycemia, vagally innervated parietal cells secreted acid mainly via cholinergic stimulation, but endogenous gastrin was also involed in varying degrees in individual patients. After vagotomy of parietal cells, however, acid secretion was mainly caused by endogenous gastrin released by endogenous adrenalin. The patients were selected for laparoscopic vagotomy as follows;1 [adrPAO (peak acid output) -adrBAO (basal acid output)]<10mEq/h.2 [adrPGO (peak gastrin putput) -adrBGO (basal gastrin output] <10, 000pg/ml/h. We performed truncal posterior vagotomy with lesser curve anterior gastric seromyotomy by laparoscopy on 6 patients (4 men and 2 woman, ranging in age from 23 and 61 years, with a mean age of 43 years. The pre-and post operative studies were based upon an analysis of the basal acid output, the peak acid output stimulated with insulin or adrenalin, 24h pressure measuremeat and pH monitoring. Postoperative decrease in insBAO, insPAO, adrBAO, adrPAO, ins (PAO-BAS) -adr (PAO-BAO) and adr (PAO-BAO) were 58, 51, 72, 106, 44 and 150 percent, respectively. These results confirmed the possibility of selectivesurgery for patients with duodenal ulcer.

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My experience with digestive endoscopy started in 1957 when I became a member of Hokkaido Univercity's Third Department of internal Medicine and received instruction in gastra-camera technique under Lecturer Masayoshi Namiki wha is naw Han-orary Professor at Asahikawa Medical College.After that I proceeded to do research on the Iarge intestine as well as the biliary tract and pancreas. I fell greatly indebted to the instruction of Dr Hikoo Shirakabe, the late Ryozo Sano and the late Satoru Soma, and Rikiya Fujita who is presently Professor of Digestive Medicine at Showa University's Fuligaoka Hospital. In the begining, ERCP contributed greatly to. the development of the diagnosis of pancreatic disease. 1Vext came diagnostic imaging such as US, EUS, CT and MRS which ail contributed to the improvement of diagnostic efficacy, However the diagnosis of early pancreatic cancer still remained elusive. Since 1988 we have been re:porting that the use of peroral micro-pancreatoscopy(PMPS) using an ultrathin fiberscape with an external diameter of 0.75mm has been very effective in the differential diagno-sis of pancreatic disease. Recently understanding of the relationship between lesions of the pancreas and surrounding blood vessels has become possible through endoscopic color-doppler ultra-sanagraghy (ECDUS). Intraductal ultrasonography(IDUS)(Civis; probe diameter:1.4mm, at 30MHz) has made it possible for the detailed observation of the area around the main pancreatic duct. Diagnostic efficacy of pancreatic disease has improved and we have had fi cases of pancreatic cancer with 5-year survival. Four of these were t₁ eases. In order to make early diagnosis of pancreatic cancer, after screening tests and observation of symptoms, EUS and ERCP should be applied. If there are abnormal findings in the pancreatic tract we shouid give precise ERP, and if appropriate, PMT'S and IDUS. In order to obtain a definite diagnosis, pancreatic biopsy and cytology should be applied.

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In this study, a fatal of 134855 patients who underwent upper gastrointestinal tract endoscopy werestudied.229 autopsy cases at our hospital between 1976and 1991, 4400 cases with liver diseases, 635 caseswith puimanary diseases and 653 eases underhemodialysis controi were also studied. Endoscopictreatment far the centrol of hemorrhage was appliedto 552 gastric and 114 duodenal ulcers. We experienced 380 cases who underwent operation due tobleeding gastric or duodenal ulcers. The incidence of gastric ulcers aut of 134855 was 5.8%, 8.0% of which was bleeding gastric ulcers. The incidence of duodenal ulcers was 2.3%, 4.3%ofwhich was bleeding orres. The incidence of active gastric and duodenal ulcers in autopsy cases was 10.7% and 4.1%, respectively. Bleeding gastriculcers were found in 13.4%of active gastric ulcers.The incidence of gastric ulcers among cases withliver cirrhosis was 6.6%, 26.5% of which was bleeding gastric ulcers. The incidence of duodenal ulcersin the same group was 2.2%, 15.3%of which wasbleeding ones. Gastric ulcers were detected in 5.0% of cases with lung cancer and in 7.4% of cases with pneumonoconiosis. Among hemodialysis cases, theincidence of gastric ulcers was 5.3%, 25.7% of whichwas bleeding ones. Among the same group, the incidence of duodenal ulcers was 1.8%, 58.3% of whichwas bleeding ones. Permanent hemostasis wasachieved in 95.2% of cases with gastric ulcers byendoscopic local injection of hypertonic saline epinephrine(HSE). Parmanent hemostasis was successfulin 86.8% of cases with duodenal ulcers. The resultsof hemostasis were greatly influenced by underlyingdiseases. Endoscopic arrest of hemorrhage seems tohave rnarkedly reduced the rate of emergency operation for patients with bleeding gastric and duodenalulcers.

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To investigate the relationship between H.pylori infection and atrophic change of gastric mucasa, biopsy specimen were taken from the gastric mucosafrom the corpus and antrum and serum IgG antibodyto H. pylori and serum pepsinogen I and II levels werealso measured in asymptomatic subjects who had nahistory of peptic ulcer. The prevalence of H.pylori infection increased with age. Mononuclear cell infil-tration was found in a1 H.pylori positive subjects, whereas only 30% of H.pylori negative subjects showed its infiltration. Pathological gastric mucosaIatrophy was seen in 31% of H. pylori'positive subjects, whereas no case who showed negative H. pylori antlhody was found any gastric mucosal atrophy.The pepsinogen I/II ratio (well-known to be a markerof gastric mucosal atrophy) was significantly lower inH, pylori positive subjects than in negative subjects.These results suggest that continuous infection of H.pylori in the gastric mucosa is thought to be a majorfactor which causes atrophic change of the gastricmucosa.

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Medical specialist systems of each medical societieshave been rapidly improving, recently. The Japancouncil of Medical Specialist(JCMS)is composed byrepresentatives from the 46 main medical societies, including Japan Gastroenterological Endoscopy Socfety(JGES)participated to the Japan Medical Society(JMS)and improve medical specialist system inJapan. In September X995, JCMS, JMS and JapanDoctor's Association authorized firstly approved spe-cialists from the 13 principal medical societies, whichsatisfied some basic conditions, as a principal medicalfield, scientific test to get each approved specialists, renewal of each approved specialists etc.. But, thzsauthorization does not mean a change of theannouncement of 25 medical fields enforced by theJapanese medical law in 1948 and is permitted onlyone medical field to one doctor, even who has morethan two approved specialists in medical fields andhas no relation to medical fee controlled strictly bythe Japanese Government. In some foreign countrieswhere are no health insurance system controlled bygovernment, a medical specialist is used to chargemuch more expensive medical fee than a generalpractitioner. Since 1981, JGES have authorized thespecialist of gasteroenterological endoscopy(GE), asapproved gastrointestinal(GI)endoscopist, approvedGE specialist(since 1987), GE director and GE educational institution, every year. However, these authorizations have enforced only by the forms from applicants. Under those circumstances, as mentionedabove, from 1995, JGES will enforce a scientific testto be entitled the approved GI endoscopist and to getahigh sccial evaluation.

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