We studied the usefulness of a method for endoscopically evaluating the Jhealingprocess of gastric ulcers by pharmacoendoscopy (PE) using a spray of the vasaactivatesubstance epinephrine to scar lesion. The changes in color tone of ulcer scars sprayed withepinephrihe was classified as showing a persistent reddish tone (P_R) or as showing a whitishtone (P_W). Assessment of the blood volume at the ulcer scar by image analysis revealedthat the blood volume at the P_R scars was about 1.5 times than that of the surroundingnormal mucosa. In contrast, the blood volume of P_W scars was only about 1.1 times thanthat of normal mucosa. Changes in color tone of ulcer scars on PE were thus confirmedto be related to mucosal blood volume. The time course of PE findings revealed that P_R was shown soon after the scarformation in most cases, and the response changed to P_W with the passage of time. Thetransfer rate from P_R to P_W depended on the depth of the ulcer. The cumulative transferrate from P_R to P_W 24 months after in ul-III scars (61%) was significantly higher than thatin ul-IV scar (22%). Cumulative recurrent rates were studied for each stage based onconventional observations and PE findings of ulcer scars. The cumulative recurrent ratesduaring 24 months after evaluation of red scars(S₁)by conventional observation was 45%, while that for white scars(S₂) was 35%. The 24-month cumulative recurrent rate for P_R scars, as evaluated by PE, was high (43%). However, the 24-month cumulative recurrentrate of P_W scars was 10%, which was lower than scars evaluated as S₁, S₂ and P_R. Inaddition, recurrence in the carne site as the originai ulcer was not noted far ulcers evacuatedas P_W even in cases possitive for Helicobacter pylori. Histological exarnination demonstrated that scars showing P_W were more mature than P_R scars. These fihdings indicatethat it is possible to evaluate the maturity of ulcer scars from the contractile function ofintramucosal vessel; ulcer showing P_W can be evaluated to have healed permanently.

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Endoscopic ultrasanography (EUS) was perfarmed in 52 patients with esaphago-gastric varices for selection of the treatment method. EUS findings of esophago-gastricvarices are as follows: 1) intramural vessels, 2) extramural vessels, 3) perforating vein (p.v.), 4) localization of the developed collateral circulation. The maximum diameters of intramural vessels were correlated with F factor ofendoscopic findings. We classified intramural vessels into 4 types (type 0, I, II, III) andextramural vessels into 4 types (type N, S, M, L) according to the maximum diameters ofthe vessels.
The perforating veins were detected in 89%of ail cases.
In 75% of all, the developed bollateral circulation was seen between the middle portionof the esophagus and cardia of the stomach. Four check points of the vascular structureof the esophaga-gastric varices were useful for making a precise diagnosis. The structure of 37 patients (71%) was classified into “ typical pattern” that was a partof upward collaterals from the left gastric vein, and 15 patients (29%) into“ atypicalpattern” .
It was suggested that the treatment method of esophago-gastric varices was chosenwith their structures based on these EUS findings. we concluded; 1) esophago-gastricvarices showing “ typical pattern” which have the maximum diameters of p. v. within 4 mmare indicated for endascopic injection sclerotherapy (EIS) . The varices of “ typical pattern” with the maximum diameters of p. v. over 4 mm sheuld be treated with combined therapy (α -cyanoacrylate monomer:CA or endoscopic variceal ligation:EVL). 2) esophagealvarices showing “atypical pattern” which have few extramural vessels are indicated forEIS, and otherwise should be choiced combined therapy.
3) gastric varices showing “ atypical pattern” which have the maximum diameters ofp.v. within 4 mm are indicated for combined therapy, and in case of the maximumdiameters of p. v. over 4 mm should be chosen surgical therapy or balloon occludedretrograde transvenous obliteration (B-RTO).
EUS is useful fcr selecting endoscepic treatment of esophago-gastric varices.

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We have developed the image processing software for finding out small gastriccancers. This would call endoscopists' attention to small gastric cancers by color enhancement of the lesions and this is useful for even dark distant views and far small lesions withfine color difference. This software consists of two steps on the programs. The first stepis to convert the original pictures into R component pictures (Rn' =Rn/Rn+Gn+Bn × M: M=average of the brightness) . The second step is to enhance this R component picture bythe extend of dynamic range and the non-linear enhancement of brightness. We appliedthis image processing method far early gastric cancers and gastric adenoma. The finedifference among colors on gastric mucosal surface was enhanced and the difference of thelesions from surrounding mucosa on colors became conspicuous for attractingendoscopist's attention. The image processing of endoscopic pictures is expected todevelop the originality in ids algorithms for the diagnostic usefulness.

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By using infrared ray electronic endoscope, which is able to observe vessels in thesubmueosal layer, we evaluated the changes before and after sclerotherapy for esophagogastric varice in 15 cases. All cases were examined with bath conventional and infraredray electronic endoscope at the same time under rapid intravenous administration ofindocyanine green. Left Gastric Arterialgraphy (LGA) was couducted before and afterscleratherapy which was performed under the image of endoscopic varicearagraphy duringinfection sclerotherapy (EVIS) in all cases. Flat varices wzthout blood flow and the rednesson the mucosa, which is different from red color sign, were not visualized by infrared rayelectronic endoscopey. In eight cases, cardiac venous dilatation could not be visualizedclearly or disappeared after the therapy, and the cases where visualization of FurrdicPlexus(FP)was not clear on the venous phase of LGA accounted for about 75% Networkof vesseles enhanced by infrared ray electronic endoscope at antrum was less clear afterthe therapy in case of which blood supply route was visualized on EVIS. In view of theabove findings, it is concluded that infrared electronic endoscope is useful for the evaiuation of the effects after sclerotherapy. It was found that FP includes a conpornent of intraluminal vein, into which sclerosantat on EVIS also flow.

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We evalhated 17 lipomas in the large intestine observed in 16 patients during the past 4-year perxo . 1.The percentage of middle-or advanced-aged patients was high, and the femaleraffia was higher. 2.The lipoma v as localized in the transverse colon-cecum in 94% of the cases. Thesize of the lipoma was less than 2 cm in 88%, and symptoms were observed in only 12%, Unlike previous studies of case collection in Japan, our results were similar to those inautopsy studies. 3. Unlike the previous reports, the correct diagnosis rate by endoscopy and that laybiopsy were high (88% and 70%, respectively). 4. Seven lipomas were treated by polypectomy, and 3 disappeared after biopsy alone.The other 7 are under course observation. 5. Recent advances in endoscopic apparatuses such as electron endoscopy and anincrease in the use of diagnostic endoscopy have allowed us a chance of detection ofasymptomatic cases and small lipomas. For these reasons, the incidence of lipoma mighthave been increased recently.

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Endoscopic cystoenterostomy was performed in 9 patients with symptomatic pancreatic pseudocysts. Endoscopic cystogastrostomy (ECG) was done in 6 cases and endoscopiccystoduodenostomy (ECD) in 3 cases. After ECG, the cysts were collapsed in 5 cases andreduced in size in one case. Relapse of the cyst was not observed in any cases after EEG.In one ECG patient, a pig tail stmt vvas inserted for permanent drainage. After ECD thecysts were collapsed and obstructive jaundice was subsided in two cases, whereas, in one ECD patent it was not effective due to the multilobulated cysts. Three complicationsocurred after ECG (one arterial bleeding and two severe pseudocyst infection). Pseudocystinfection ocurred in cases presenting a large amount of debris in the cystic lumen. Although endoscopic cystoenterostomy is an effective procedure in the restricted cases, itsindication and potential risk of complications must be discussed fu.rther.

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A69-near-old man had been followed up for the duodenal polyp since 1987. In 1992, the endoscopic biopsy revealed adenoma with moderate cellular atypism. In December 1993, he underwent endoscopic snare polypectomy without any troubles. The resected polyp was a pedunculated type with lobular appearance, measuring 22× 12× 5mm in size. Histalogical examination of the resected polyp revealed marked hyperplasla of the duodenal superficial and foveolar epithelial cells intermingled with adenomatous foci. There were 18 reported cases of duodenal hyperplastic polyp resected by endoscopic polypectomy in Japan. However, duodenal polyp with these histological characteristics such as the present case is not found in the literature.

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A 50-year-old male was diagnosed to have swelling duodenal papilla of Vater on uppergastro-intestinalgraphy. The papilla showed reddish, granular and swelling on duodenoscopy. Histological diagnosis of biopsy specimens was adenoma. Intraductal ultrasonography (IDUS)revealed no tumor infiltration to the papi11ary pancreatic duct or bile duct. Weperformed endoscopic papillectomy under the informed consent. The tumor was resectedcompletely without complication.9months after papillectomy there is no sign of recurrence. IDUS with high resolution imges, which can demonstrate the duodenal papillaryregion in detail, is useful for the determination of indication of endoscopic papillectomy.

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A57-year-old woman was admitted to our hospital complaining of melena and abdominal pain. Ultrasonography showed a‘ target-like sign’ suggesting a small intestinal intusscseption. Barium meal study of the small intestine showed a mobile, pedunculated jejunal tumor near the ligament of Treiz, and endoscopy also revealed a pedunculated tumor With a reddish lobulated head. A hamartoma was suspected from the bioptic specimen. The pathological diagnosis of the resected specimen was a jejunal hamartoma (Peutz-Jeghers type) with.adenomatous changes, severe dysplasia, and foci of carcinoma. Although hamartomas of Peutz-Jeghers syndrome (PJS) are not uncommonly associated with carcinoma, our case was a solitary one, which was thought to be rare. Thus, it is suggested that even a solitary hamartoma also may progress to carcinoma through adenomatous change and/or dysplastic change. Moreover, we described that the history of intermittent abdominal cramps should be the most important clue to the diagnosis of small intestinal tumors.

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A 61 year-old male had a 20-year history of lower leg edema and anemia. The patient was malnourished and laboratory tests revealed anemia and hypoproteinemia. Colonoscopy revealed a fistula between the jejunum and the transverse colon near the splenic flectu.re. It seemed that the anemia and malnutrition were caused by malabsorption due to this fistula. Surgical resection vas performed. At laparotomy, some diverticula were found on the opposite side of the attachment of the small intestine, and one of them formed a jejunocolic fistula. A strong adhesion was found throughout the colon and small intestine. Histologically, the diverticulum was a true diverticulum, and there was an aberration of gastric mucosa, but no ulceration. Therefore, it was considered that this fistula was probably formed as a result of penetration of a jejunal diverticulum. This case is very rare because only one case of penetration of a Meckel's diverticulum has been reported previously in Japan.

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A 69-year old man was admitted with the chief complaint of melena. He was currentlyunder treatment with corticosteroids for bullous pemphigoid. On colonoscopic examination, multiple ulceratians were found in the sigmoid colon. On the lllth day of admission, he was rushed to emergency surgery for panperitonitis and intestinal perforation wasfound. Pulmonary lesions were pr7sent before the operation and got worse after operation.The diagnosis of pulmonary tuberculosis was made by bronchofiberscope and the diagnosisof intestinal tuberculosis was comfirmed by histological findings of the resected intestine.Colonic tuberculosis was suggested by healed sigmoid colon lesians with treatment fartuberculosis. This paper reported a case of perforated intestinal tuberculosis, which isrelatively rare in Japan.

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Arare case of rectal carcinoma in adenoma producing CA19-9 is reported. A patientwas a 72-year old man admitted to our hospital because of high level of serum CA19-9elevated to 550 U/ml. X-ray and endoscopic examination revealed an elevated lesion in therectum. Well differentiated adenocarcinoma in adenoma was cofir:med histologically, Partial resection of the rectum was performed. Histopathological examination disclosedwell differentiated adenocarcinoma in adenoma involving mucosal layer. CA19-9 wasdemonstrated in the cancer cells with 5AB method. No sign of recurrence was observedfor 12 months after operation.

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The patient was a 27-year-old woman who had been hospitalized twlce ln one year and 9 rnonth with a diagnosis of non-A, non-B, non-C acute hepatitis. The laparoscopic examination at the initial admission revealed an ectopic liver tissue measuring 4× 10mm was found on the surface of the serous membrane at the base of the gallbladder. The second laparoscopy during the third hospitalization showed that the ectopic liver tissue had become thinner. In addition, the liver biopsy specimen indicated progression of the disease into chronic active hepatitis. It seems that process of chronic active hepatitis in this patient caused drop-out of the hepatocytes and thinning in the ectopac layer ta55ue. As for the etiology of this hepatitis, known viral markers and autoantihodies were all negative and the condition does not agree with the current diagnostic criteria fo rautoimmune hepatitis. The patient has no history of alcoholic drinking or exposure to drugs. Further investiga-tion is required to determine the pathogenesis.

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Endoscopic variceal ligation (EVL) was performed ln 50 patientS with severe eso-phageal varices from October 193to July 194. These cases were evaluated to assess theclinical efficacy and safety of EVL. In all patient, the grade of variceal form in endoscopywas significantly reduced by this procedure (average series of EVL: 1.8). The varicealeradication (FO and negative RC-sign) was achieved in 28.6%and the variceal improve-rnent (FI and negative RC-sign) was obtained in 57.1%of the patients. The acute bleedingfrom esophageal varices was controlled by EVL in 88.9%of emergent cases. No mayorcomplication of this procedure was identified. Antibiotics were prophylactically adminis-tered in 3a cases to evaluate whether the relating complications could be, diminished. Nosignificant difference in the development of both pyrexia and chest pain was found betweenpatients with and without antibiotics administration. The variceal recurrences weredetected in 75%of patients with eradicated varices with the average period of recurrence158± 80days after a series of the procedure. EVL had a sufficient hemostatic effect in bleeding cases from esophageal varices, andimproved both variceal form and RC-sign without serious complications. It was evidentthat more frequent series of EVL were necessary to achive variceal eradication, especiallyin cases with advanced form and severe RC-sign of varices. However, early recurrencesof varices were identified in more than half of cases with variceal eradication. It seemsthat single application of EVL for severe esophageal varices has a risk of early varicealrecu.rrence. Thus, frequent endoscopic follow-up of eradicated varices should be necessaryto prcvent variccal hcmorrhage.

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Endascoptc ultrasound (EUS) -guided needle biopsy was performed on a 55-year-oldman with an extragastric leiomyosarcoma. The apparatus used was newly developedprototype endoscopic u.ltrasound tranducer PR192 (Toshiba Co., Tokyo, Japan) and biopsyneedle designed far the purpose of perfarming EUS-guided puncture. The presumptive diagnosis of the solid and cystic tumor anterior to the pancreas andposterior to the stomach could be made by conventional cross-sectional imaging modalitiesand angiagraphy, but histological comfirmation was still required, EUS revealed thecontinuity between gastric mural architechture and the tumor, and the specimen obtainedby following EUS-guided needle biopsy comfirmed leiomyogenic tumor microscopically.The resected specimen comfirmed leornyosarcama. Thus, the difficulties in determiningaccurate diagnostic criteria for leiomyogenic tumors are well known, EUS-guided needlebiopsy will assist the assessment in cases of diagnostic difficulties. These apparatusshoa-ed goad maneuverability during the procedure.

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